As we have reported previously, following successful advocacy from ASCRS and the ophthalmic community in 2018, CMS created a unique J-code for the medication used during the corneal collagen cross-linking procedure, for use beginning on January 1, 2019. While cross-linking is not covered by all commercial plans, there has been a significant increase in the number of plans that do cover it, including most of the Blue Shield plans, Aetnai, and Kaiser Permanenteii. A full list of payers with positive coverage policies is available at www.livingwithkeratoconus.com.
To assist physicians and practices in furnishing this service, ASCRS is providing updated billing guidance.
The FDA approved the Avedro KXL System with Photrexa and Photrexa Viscous in April 2019. Since that time, the service was billed with a Category III CPT code, 0402T – Collagen cross-linking 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. Many cross-linking claims have been denied or rejected for invalid CPT and invalid NCD codes.
While the Category III code, 0402T, will remain for the procedure, as of January 1, the new J-Code, J2787, should be used instead of the unspecified code. Since many of the claims processing challenges have been related to that unspecified medication, this new code should reduce the uncertainty surrounding reimbursement.
January 1, 2019, Correct Coding
0402T – Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
J2787 – Riboflavin 5’- Phosphate, ophthalmic solution, up to 3ml
Since the procedure requires the use of 6 ML of solution, submit 2 units of J2787 when performing the corneal cross-linking procedure.
The NDC number and description for the Photrexa cross-linking kit remain: NCD 25357-025-03—Photrexa cross-linking 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 ensure that you have added 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
Despite the existence of a CPT code and a specified medication code, coverage is not guaranteed. It is recommended that practices verify coverage before performing each procedure.
- Positive coverage policy: If your patient’s insurance has a positive coverage policy and you participate with the plan, you should not bill the patient, even if you suspect the insurance payment may not cover the cost of both the procedure and drug. This would most likely violate your contract.
- Negative coverage policy: You may collect payment from the patient.
- No published policy: Contact the carrier. You cannot assume non-coverage. If you collect from a patient and he or she then submits the claim and obtains coverage, you will likely have to refund the fees you have collected. The insurance reimbursement may be lower than expected, and appeals after the claim has been underpaid require a great deal of work. You should contact the carrier before performing the procedure.
The unique J-Code allows insurance carriers to establish a price for the medication unit. Many insurance carriers will establish a reimbursement rate based on one of the following:
Weighted Average Cost (WAC) – As of December 2018, the WAC per package is $2,850.iii The WAC per unit would be $1,425.
Average Wholesale Pricing (AWP) – As of December 2018, the AWP is $3,420.iv The AWP per unit would be $1,710.
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 to verify the requirements of each insurance carrier.
Also, it is important to note that many of the coverage polices require documented progression of keratoconus. Some policies are more specific than others. Read and share the progression requirements and ensure physicians document the medical necessity clearly in their chart notes. To obtain a prior authorization, you often need to send in chart notes, and many insurance carriers are requesting chart notes before processing these claims. Be sure that your documentation clearly supports the prior authorization and the claim.
i Aetna Coverage Policy available at: http://www.aetna.com/cpb/medical/data/1_99/0023.html. Accessed 01/06/2018
ii Kaiser Permanente Coverage Policy available at: https://provider.ghc.org/all-sites/clinical/criteria/pdf/crosslinking.pdf. Accessed 01/06/2018
iii Pricing as listed by First Databank, Medi-Span and Redbook.
iv Pricing as listed by First Databank, Medi-Span and Redbook.