Eyeworld

APR 2018

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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10 EW ASCRS NEWS J-code for riboflavin. He recounted that HCPCS declined to create a J-code because it is an inherent part of the procedure. He added that use of J3490 represents fragmentation of a claim and could be construed as a duplicate bill. While there is present- ly a lot of discussion about wheth- er or not physicians should use a J-code, it's apparent that HCPCS has already answered the question, he said. The CPT code describes cross- linking, and you do that with ribo- flavin. "If you think about it," he added, "it's impossible to do cross- linking without riboflavin." Sara Rapuano, consultant and former chief operating officer, Wills Eye Ophthalmology Clinic, Philadelphia, said, "We're finding the majority of our patients come in with coverage from their insur- ance companies. The challenge is that, unfortunately, even though they cover it, they're not necessar- ily paying enough." This requires educating insurance representatives. Ms. Rapuano said that a predetermi- nation should be done for each case, explaining why and how crosslink- ing is performed. She also noted that underpay- ment remains a significant chal- lenge. This can require follow-up to explain to the payers why it should be covered more fully. Ms. Rapuano also comment- ed on the use of the Category III code and the debate on whether to submit in the J-code, observing that generally in predetermination they note to the insurance compa- nies that they would like the J-code to be used and are asking if this is acceptable. "To date, we haven't had anyone say no to submitting the J-code," she said. EW Editors' note: Dr. Rajpal and Dr. Zadno have financial interests with Avedro. Mr. Corcoran, Ms. Rapuano, and Ms. Shuren are consultants. Drs. Mah and Tu have no financial interests related to their comments. Contact information Corcoran: kcorcoran@corcoranccg.com Mah: Mah.Francis@scrippshealth.org Rapuano: sbrapuano@gmail.com Rajpal: rrajpal@seeclearly.com Shuren: Allison.Shuren@arnoldporter.com Tu: etu@uic.edu Zadno: reza@avedro.com If the procedure is covered, Dr. Rajpal said they are usually able to determine if the drug can be billed separately from the procedure using the miscellaneous J-code. "If the carrier says bill it all together, we do. If they say bill separately, we do," he said. Determining coverage takes time, Dr. Rajpal noted, because most insurance carriers don't have a specific amount for it. If the carrier initially denies coverage, it is pos- sible to overturn this decision, and Dr. Rajpal said he has seen initially low payment amounts get increased. In his practice, he's seen a range of payments, and the combined drug and the procedure have averaged approximately $4,100. Dr. Rajpal said he follows the AAO guidelines on whether to use a J-code and their recommendation to check with the insurance carrier regarding whether they prefer the drug to be billed separately, he said. Elmer Tu, MD, Chicago, Cornea Society president, said, "The sub- stantial, unexpected increase in the per case cost put in place last July has led to unprecedented uncertain- ty for both patients and physicians. For physicians, these changing costs, after an already large capital invest- ment in the technology, have made it difficult to provide an essential, potentially sight-saving procedure to their patients in a predictable, cost-effective environment. This guarantees a long, involved process in approval for treating patients and complicates counseling them on the potential costs involved for the foreseeable procedure. Patches to the process, like ARCH, are welcome, but existing billing contracts may prevent some practices, like ours, from fully utilizing them." Dr. Tu said that in one, narrow respect the J-code is beneficial if it is recognized and reimbursed fully by third-party carriers in that the physician is insulated from future price changes. If, however, the reim- bursement is either not recognized or fully reimbursed, it will dissuade both physicians and patients from pursuing the therapy, especially if the cost remains at this level, he said. "Ultimately, explaining the costs of the procedure should not exceed the complexity of the procedure itself, and I am not sure that this is currently the case," Dr. Tu said. Francis Mah, MD, La Jolla, California, ASCRS Cornea Clinical Committee chair, said in California, there is coverage around 40–50% of the time. A question that comes up is how much people get when they bill for it. Sometimes everything requested is covered and sometimes not even the drug is covered. Additionally, Dr. Mah pointed out the difference of opinion on whether a J-code should be used. The Category III code used for cross- linking (0402T) specifically men- tions removing the epithelium and pachymetry but doesn't mention the drug, Dr. Mah said, even though you can't do the procedure without the drug. He said that AAO states that the CPT code does not address the medication used in the procedure, and they're recommending use of a J-code. "That's the crux of the debate," he said. "Do you or do you not use a J-code?" J-codes are supposed to be used for things that are not part of the procedure, he said, yet this is central to the procedure. With this difference in opinion, Dr. Mah said that some insurances are taking the J-code and some are not. "You have no idea how much you're going to get from the insurance, but you have to take what the insurance gives you," he said. "There have been instances where people have done the procedure and they got less than they needed to even cover the drugs." Allison Shuren, Arnold & Por- ter Kaye Scholer LLP, Washington, D.C., said that when the procedure launched after FDA approval, there was no coverage and reimbursement through commercial or govern- ment payers, so physicians charged patients directly out of pocket. The procedure is now being covered by some payers, and the company is working to make sure payers are aware of the procedure and patient outcomes, and seeking coverage policies for it, Ms. Shuren said. Physicians should be in discus- sions with their payers regarding their patients in need of crosslinking to determine coverage, payment, and how the payers want the claim submitted—with the category III CPT code for the professional service and a J-code for the drug or as a bundled service, she said. Despite increasing coverage for crosslinking, Ms. Shuren noted that there are not many formal policies yet. Right now, a couple of payers have articulated their policy on payment and others have done it for one-off requests, she said. However, when it has been reviewed and plans understand the underlying disease, they generally cover it, she added. But the question remains if they're paying sufficiently for it. Kevin Corcoran, COE, CPC, CPMA, Corcoran Consulting Group, San Bernardino, California, said the recent Photrexa price increase by about five times the original price has raised significant concerns for ophthalmologists because they weren't expecting it. Though some payers now reim- burse the procedure, Mr. Corcoran noted that the amount of reim- bursement has created a problem for surgeons because payers might not reimburse the total billed amount for the crosslinking procedure in- cluding riboflavin. In terms of whether a J-code should be used, Mr. Corcoran point- ed directly back to the HCPCS Final Decision in late 2017 in response to Avedro's initial application for a April 2018 Crosslinking continued from page 3 Crosslinking received U.S. FDA approval in April 2016, however, questions regarding reimbursement remain, as it will not be covered by all private payers and is often determined on a case-by-case basis.

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