Reimbursement for In-Office Vitrectomy (Insight Instruments)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR IN-OFFICE VITRECTOMY
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Q What is the Intrector® Portable Vitrectomy System?
A The Intrector System is a portable, single entry, variable speed, guillotine-style vitreous cutting system using manually controlled aspiration and infusion. There are two probes available: the Intrector dual chamber probe and the Retrector™ Retractable Sharp-Tip Vitrectomy Probe. They are inserted transconjunctivally through an oblique 23 gauge sclerotomy into the vitreous. Unlike most other vitrectomy instruments, the Intrector provides the capability for in-office vitrectomy.
Q What are the indications for using the Intrector?
A The Intrector is intended for the removal and substitution of vitreous matter from the vitreous cavity during ophthalmic surgery. Common indications include:
- Vitreous hemorrhage
- Core pars plana vitrectomy (PPV) for diabetic retinopathy, retinal vein occlusion, or other secondary causes of macular edema in concert with drug infusion
- Removal of significant vitreous floaters
- PPV for complications of anterior surgery (shallow chamber or vitreous loss)
- Vitreous biopsy for endophthalmitis and uveitis at the bedside or in the office
- PPV with pneumatic retinopexy
Q What are the contraindications for use of the Intrector?
A Contraindications include:
- Inadequate view through the visual axis
- Procedures requiring physical manipulation of the retina
- Extensive peripheral retinal pathology
Q What CPT codes describe procedures using the Intrector?
A Choice of an appropriate CPT code depends on the procedure and the indication(s). Several possibilities exist:
67015 …“Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy)” for cases involving vitreous chamber tap
67025 …“Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure)” for cases involving gas-fluid exchange
67027 …“Implantation of intravitreal drug delivery system (e.g., Ganciclovir implant), includes concomitant removal of vitreous” for cases involving PPV with implants such as Ozurdex® (J7312, 0.1 mg – bill 7 units) or Vitrasert® (J7310, 4.5mg)
67036 …“Vitrectomy, mechanical, pars plana approach” for cases involving core PPV
67108 …“Repair of retinal detachment … with vitrectomy, any method, with or without air or gas tamponade … and/or removal of lens by same technique” for cases involving PPV with air or gas tamponade
Q Do Medicare and other payers cover the procedure?
A Yes, for medically indicated reasons. A partial list of covered diagnoses appears below; check your local coverage policies.
67015 …360.0x, 360.1x, 364.02–364.04
67025 …361.0x, 361.30, 362,35, 362,36, 362,83
67027 …363.20, 364.02–364.04
67036 …360.0x, 360.1x, 362.02, 362,35, 362.36, 362.83, 364.02–364.04, 379.23–379.24
67108 …361.0x, 361.30
Q May we bill for more than one of these codes at the same time?
A Usually not. Medicare’s National Correct Coding Initiative (NCCI) edits as of January 1, 2013 include:
67015 …67025, 67028
67027 …67015, 67025, 67028, 67036
67036 …67015, 67025, 67028
67108 …67015, 67025, 67028, 67036
Q What is the facility reimbursement for these procedures?
A All of the codes discussed in this FAQ are classified into APC 672. In a HOPD, the national 2013 Medicare allowable is $2,913.76. In an ASC, the national 2013 allowable is $1,635.00. These amounts are modified by local indices, so actual payments will vary.
Q What does Medicare allow physicians for these procedures?
A The 2013 national Medicare Physician Fee Schedule allowable amounts are shown below. There is no separate reimbursement for supplies.
These amounts are adjusted by local geographic indices; actual payment amounts will vary.
Q Are there any payer limitations governing where the Intrector may be used?
A No. The setting for surgical procedures is a decision made by the surgeon based on clinical needs and preferences. There is no prohibition on place of service based solely on the values in the Medicare Physician Fee Schedule. CMS states, “… some procedures have a separate Medicare fee schedule for a physician’s professional services when provided in a facility and a nonfacility”.1.
If the procedure is not done in the physician’s office, then Medicare pays a separate facility fee to the HOPD or ASC, and may reduce the surgeon’s professional payment since the office was not used to treat the patient.2. See the allowed amounts in Q8, above.
1. MCPM Chapter 12, §20.4.2
2. Federal Register Vol 75, No228, page 73184, Nov 29, 2010.
Provided Courtesy of Insight Instruments, Inc. (772) 219-9393 (800) 255-8354
Last updated March 13, 2013
The reader is strongly encouraged to review federal and state laws, regulations and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on all matters pertaining to reimbursement. The reader is also reminded that this information, including references and hyperlinks, can and does change over time, and may be incorrect at any time following publication.
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