February 2019


Coding and reimbursement update for corneal collagen crosslinking

Corneal collagen crosslinking provides a treatment that can stop the progression of keratoconus and ectasia after refractive surgery. There is optimism that initial reimbursement challenges will be reduced now that the approved Photrexa medication for the procedure has a unique J code, which allows insurance carriers to establish a price for the medication unit.
Since the FDA approved the Avedro KXL System with Photrexa and Photrexa Viscous in April 2016, ophthalmic practices have billed this service with a Category III CPT, 0402T – Collagen crosslinking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed) and an unspecified HCPCS Code, J3490 – Unspecified medication. New technology codes and unspecified codes pose specific challenges to reimbursement. New technology codes have no RVUs assigned to them and therefore often lack a set fee schedule amount, while the unspecified J codes cause numerous claim submission formatting challenges.
ASCRS worked diligently with the ophthalmic community to address the lack of a specific J code and is pleased to share a summary of guidelines for correct coding of crosslinking as of January 1, 2019. ASCRS and ASOA strongly encourage ophthalmologists and administrators who offer crosslinking to go to ascrs.org/Corneal_Cross_Linking_Billing_Guidelines for details.

January 1, 2019 correct coding

While the Category III code, 0402T, will remain for the procedure, as of January 1, the unspecified J code no longer needs to be used. CMS has released a new, specific HCPCS code for the medication used in corneal crosslinking, effective as of January 1, 2019.
• 0402T: Collagen crosslinking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
• J2787: Riboflavin 5’– Phosphate, ophthalmic solution, up to 3 ml
Since the procedure requires the use of 6 ml of solution, offices should submit 2 units of J2787 when performing the corneal crosslinking procedure.
The NDC number and description for the Photrexa crosslinking kit remain:
• NCD 25357-025-03: Photrexa crosslinking kit
Many carriers require that you submit claims with an 11 digit NDC. To convert the 10 digit NDC to 11 digits, add a zero to the NDC as follows: 25357-0025-03. It is important to add this new HCPCS code to your charge master effective January 1, 2019 and that you have appropriately programmed in the NDC so it is ready for procedures performed after January 1, 2019. Claims for date of service through December 31, 2018 should still be submitted with J3490 – Unspecified medication.

Commercial carrier coverage

The existence of a CPT code and a specified medication code does not ensure coverage, however. You still should verify coverage before performing each procedure.
• Weighted Average Cost (WAC): As of December 2018, the WAC per package is $2,850. The WAC per unit would be $1,425.
• Average Wholesale Pricing (AWP): As of December 2018, the AWP is $3,420. The AWP per unit would be $1,710.
It should be noted that while many insurance carriers do not require prior authorization for outpatient surgical procedures, they may require one for 0402T because it is a new technology code and many do require prior authorization for billable medications such as J2787. Make sure your office verifies the requirements of each insurance carrier.

Contact information

Nancey McCann
: nmccann@ascrs.org

Coding and reimbursement update for corneal collagen crosslinking Coding and reimbursement update for corneal collagen crosslinking
Ophthalmology News - EyeWorld Magazine
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