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With new AMD therapy, insurers sometimes need a nudge
Taking a proactive approach helps get speedy reimbursement for new retinal therapies.
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KOLOA, Hawaii – Getting reimbursed by insurers for relatively new procedures such as photodynamic therapy (PDT) and transpupillary thermal therapy (TTT) can be challenging. But if you adequately support your claims and use the appropriate coding, the battle is all but won. Jay S. Duker, MD, discussed reimbursement for AMD treatments here at Retina 2001, presented with Hawaii 2001, the Royal Hawaiian Eye Meeting, sponsored by Ocular Surgery News in conjunction with the New England Eye Center.
“By taking a proactive approach with local carriers and giving them supporting information such as the retrospective studies that have already been published on TTT, you may be able to work with them on getting payment for this. Once the results for the TTT for CNV Trial become available — if it shows a benefit — then there will not be a problem with this being an accepted procedure for occult choroidal neovascularization,” Dr. Duker said.
He said Novartis, which distributes Visudyne, recommends that a letter of medical necessity, specific to the patient’s condition, be submitted when reimbursement is sought.
“At the New England Eye Center, we have a standard letter we developed that talks about age-related macular degeneration and loss of vision and provides some of the Treatment of Age-Related Macular Degeneration with DPT (TAP) Study data and says this is the best treatment for this underlying condition,” he said.
A common language
Coding provides a common language between physicians and insurers, Dr. Duker pointed out.
“So, of course, it is relevant to get the proper coding. Once the coding is submitted, then the insurance companies have to decide if this is a covered service or not,” he said.
The CPT code for PDT is 67221, destruction of localized lesion of the choroid using ocular PDT. The appropriate process for seeking reimbursement for TTT has changed several times in as many months. The most recent policy dictates that physicians manually submit the reimbursement request along with information regarding medical necessity under the code G0185, destruction of localized lesion of the choroid/transpupillary thermal therapy.
Local and Medicare carriers may have their own coding and billing requirements separate from national carriers.
“Before filing any claims, providers should verify these requirements with the local carriers. We can make broad general statements about reimbursement and billing on a national level, but the local carriers at each state can basically do whatever they want,” Dr. Duker said.
About one-third of the states are reportedly paying for TTT at present, according to Dr. Duker.
“If you are practicing in one of the states where local carriers are not paying for TTT, but you and your patient are convinced it is the right thing to do, you can have the patient sign a waiver called an Advanced Beneficiary Notice. If the patient agrees, and signs this waiver, you can collect the money for the treatment up front,” he said.
With PDT and TTT, it can help tremendously if additional materials supporting the claim are included with the request for reimbursement.
“It can really help if you explain what these procedures are and why you believe they are helpful. If you can develop a relationship with the medical director of the local carrier, that can be extremely helpful as well. Once they decide that you didn’t just make this up, they may actually pay you for the procedure,” he said.
Medicare’s policies
Almost all the patients treated for age-related macular degeneration are over 65, but not every patient treated with PDT is over 65.
“Private payers and HMOs will certainly have their own decisions about coverage, but for the most part, they are going to follow Medicare’s policies. Understanding the Medicare policy coverage and payment is really crucial to getting reimbursed for your efforts,” Dr. Duker said.
Medicare will only pay for services determined to be reasonable and necessary for the diagnosis and treatment of illness or injury, and to improve the functioning of a malformed body member. So these treatments must be necessary for diagnosis and treatment of disease and, of course, fit into a Medicare benefit category.
“Medicare is only going to understand certain categories of disease, so if you are billing, for example, PDT for choroidal neovascularization, you must submit this under the proper diagnosis, which is nonspecific neovascularization,” he said.
Visudyne’s average wholesale price (AWP) is $1,535. The Medicare allowable is 95% of the AWP, or $1,458.
“Medicare will only pay 80% of covered services and drugs in general,” Dr. Duker said. “Most patients have supplemental insurance for the other 20%, but not all. Physicians are obligated to charge for the remaining 20%, otherwise they run the risk of being cited for fraud and abuse.”
Follow-up PDT treatments are also covered.
“There is no global period. You can re-treat at any point and supposedly you will get paid for it. You can bill for the 1-month follow-up visit; you can bill for the fluorescein angiogram and you should get paid for it,” he said.
For Your Information:
- Jay S. Duker, MD, can be reached at 750 Washington St., Box 450, Boston, MA 02111; (617) 636-4604; fax: (617) 636-4866; e-mail: jduker@lifespan.org.