With some common ophthalmological drugs paying more than $300 per mg and individual treatments requiring multiple milligrams, you can’t afford to report less of a dosage than administered.
To ensure that you get properly reimbursed on the amount of drugs administered, follow a few simple steps.
- Report the Injection Code With Modifier
There are three common injections that an ophthalmology practice often performs. Report the injection procedure with a CPT procedure code as follows:
- For a sub-Tenon injection, report 67515 (Injection of medication or other substance into Tenon’s capsule).
- For a subconjunctival injection, use 68200 (Subconjunctival injection).
- Code an intravitreal injection such as of Kenalog-10, Avastin, or Jetrea with 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]).
Indicate the eye that the specialist injected with the appropriate laterality modifier (RT, Right side; LT Left side) or modifier 50 for bilateral. For bilateral reporting, check with payers whether they want modifier 50 or two lines with -RT and -LT.
- Use a J Code for the Drug
For the medication, report a HCPCS J code:
- For an intravitreal injection, you’ll report Avastin using J9035 (Injection, bevacizumab, 10 mg).
- For Eylea, use J0178 (Injection, aflibercept, 1 mg).
- To report Lucentis, use J2778 (Injection, ranibizumab, 0.1 mg).
- For Kenalog-10 and Triesence, use J3301 (Injection, triamcinolone acetonide, per 10 mg) for the supply of the drug.
- For Jetrea, report J7316 (Injection, ocriplasmin, 0.125 mg).
- Report Units Based on Descriptor and Administration Amounts
Bill the number of units based on the number of milligrams indicated in the J code descriptor and the amount of the drug administered.
When CMS Recovery Auditors reviewed claims, the most common billing error found was forgetting to convert milligrams to units. Source: MLN Matters® Number: SE1316.
Example: Eylea HCPCS description of drug J0178 (Injection, aflibercept, 1 mg) code indicates 1 mg. If the retinal specialist administers 2 mg of Eylea, bill 2 units total – 1 unit for each mg administered.
Eyes Open: Lucentis single vials come in two sizes. Be sure to check the NDC to determine the amount that the provider is using.
If you report one unit for Lucentis instead of five for 50242-0080-01, you’ll underbill the drug by approximately $1,530. Since the medically necessary amount of injections is three, you’d lose almost $5,000 for the drug order. With the high cost of these drugs, correct billing is imperative for financial health.
Documentation should indicate the drug administered and the milligram amount administered. The biller can then convert the milligrams to units. Below, the unit conversions for eight top injectibles’ recommended doses:
|Lucentis||3 units for National Drug Code (NDC) code|
|5 units for NDC code 50242-0080-01|
Step 4: Report the NDC Code
Make sure you put the NDC code in box 19 of the CMS 1500 Claim Form or online version. Without the number, the insurer will reject the claim, delaying cash flow.
Got a superbill? This clip ‘n’ save chart will help eliminate drug-unit mismatches.