CMS Delays Bundling of Intravitreal Injection and Eye Codes Indefinitely

In response to significant concerns raised by ophthalmology groups including the California Academy of Eye Physicians and Surgeons, the American Academy of Ophthalmology, and the American Society of Retina Specialists, the Centers for Medicare and Medicaid Services (CMS) has indicated it will delay implementation of National Correct Coding Initiative (NCCI) edits that would have "bundled" intravitreal injections (CPT 67028) with Ophthalmological services (CPT 92012 and -14). The change was slated to be effective July 1, 2014.

In a letter to Correct Coding Initiatives, LLC (CCI), the CMS contractor charged with maintaining the edits, CAEPS argued implementation of the edits would disincentivize techniques to reduce the number of injections in a course of treatment of wet macular degeneration, thus potentially creating additional costs to the Medicare program related to drugs such as Lucentis and Eylea, far outstripping any savings from excluding the exams, on the order of upwards of $400 million annually.
Although not specific, CCI's response indicates the purpose of the delay is to "consider a number of issues related to CPT 62078."
While it would have been possible to "unbundle" the codes using the -25 modifier if the exam were a "significant, separately identifiable service," language published regarding the edits specifically indicated "[i]f the patient [receiving treatment for wet ARMD] is only examined to determine the need for an injection in the eye scheduled for treatment, then a visit should not be billed," which appears to have been a frequent occurrence to date.

It should be noted that the excluded reimbursement from the edits would have been in addition to a recent reduction of the Relative Value Units of the intravitreal injection code intended to address the fact that both an exam code and the injection code were frequently billed together, making the reduction and the edits duplicative.

No specific period of delay has been indicated, but it is anticipated several months notice of any future change would be given.

Please contact CAEPS at should you have any questions regarding this issue


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The California Academy of Eye Physicians and Surgeons (CAEPS) is the only statewide organization representing California ophthalmologists and their patients. CAEPS' activities include legislative advocacy, interaction with third party payers about reimbursement and coverage issues, public education about important eye health care concerns, and continuing medical education for ophthalmologists and their staffs.

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