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Reimbursement for Omidria

Omidria (phenylephrine and ketorolac injection) 1% / 0.3% is used during cataract and lens replacement surgery (i.e., refractive lens exchange or IOL exchange) to maintain pupil size by preventing intraoperative miosis (pupil constriction) and to reduce postoperative pain. Each 4-ml single-patient-use vial of Omidria is diluted in a standard 500-ml container of irrigation solution for use during the procedure; it requires no change in the surgeon’s operating routine. The Food and Drug Administration (FDA) approved Omidria on May 30, 2014.

 

This FAQ addresses the following:

  1. What is Omidria®?
  2. Is Omidria indicated for intra-ocular surgery other than lens extraction or lens exchange?
  3. What CPT code(s) describes cataract surgery with IOL placement?
  4. What CPT code describes refractive lens exchange?
  5. Do Medicare and other third party payers cover Omidria?
  6. Is there separate payment to the HOPD or ASC for Omidria?
  7. What is the Medicare facility reimbursement for Omidria?
  8. What HCPCS code is used on claims for reimbursement for Omidria?
  9. Is Omidria subject to the Medicare copayment rule?
  10. Does the use of Omidria affect the surgeon’s reimbursement?
  11. Are there purchasing concerns related to Omidria?

 

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