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Coding

Medicare to review retina services

Government scrutiny of intravitreal injections appears to be increasing.

This month’s coding column is about how to document services surrounding intravitreal injections, because scrutiny by the government appears to be increasing. We have covered some of this before in this column. These past articles reviewed tests and orders1 for intravitreal injections, documentation of the drugs2, injection operative notes3, and the proper use on claims of modifier 25.4

Recently, the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) announced it would review the services associated with two common retina drugs, Lucentis (Genentech) and Eylea (Regeneron), and issue a report sometime in 2020.5 In this announcement, the HHS OIG stated:

“We will review claims for intravitreal injections of Eylea and/or Lucentis and the other services billed on the same day as the injection, including evaluation and management services, to determine whether the services were reasonable and necessary and met Medicare requirements.”

What does this mean to you as a technician?

First, be sure and chart appropriate for these two drugs. Include a note of any overfill and that it’s disposed properly (not used). Records might be requested by the OIG. If they are, your office must release them and cannot charge OIG for that. The records you send will include:

  1. The intravitreal injection itself (the operative note from your chart with lot number, expiration, dose administered)
  2. Anything else that surrounded the injection, which includes:
    1. The exam your doctor did to determine the need for the injection of these two drugs — even if you did not file that exam with modifier 25.
    2. The test results that confirmed the need for these drugs — OCT order, interpretation, and OCT image for the date being reviewed by OIG. (The OCT or other test might have been ordered before this injection date being reviewed.)

Second, evaluate current processes. Be sure the above-mentioned processes are solid or make changes. You should also be sure your office keeps good ordering, use, and purchase records of any drugs. Consider one of the bar-coded commercial solutions; you do need to track an individual drug and vial to an individual patient’s eye or risk having paid monies recouped by the payer due to lacking records.

Third, support your doctors. It’s not up to you to discuss with any patient which drug your doctor decides they should use. Remember that “We’re not doctors,” and they choose what they think is best; our job is to support that decision.

Conclusion

Payer scrutiny of things (drugs, surgeries, or tests) that happen often are part of the healthcare landscape now. When new drugs come out, or new processes, get the proper training for yourself and your fellow colleagues you will be doing your office a tremendous service and increasing your value. You will also be able to help your offices keep any monies received if reviewed, which is always a good thing.

As always, “good coding to you.”

REFERENCES:

  1. OP. Coding. Orders for Diagnostic Testing. July 2017. bit.ly/OPCoding717 . Accessed 08/07/19.
  2. OP. Coding. Medications Associated with Intravitreal Injections. September 2013. bit.ly/OPCoding913 . Accessed 08/07/19.
  3. OP. Coding. Operative Notes for Intravitreal Injections. July 2013. bit.ly/OPCoding713 . Accessed 08/07/19.
  4. OP. Coding. Modifiers 25 and 57: Appropriate Use. July 2015. bit.ly/OPCoding715 . Accessed 08/07/19.
  5. HHS OIG. Review of Medicare Part B Claims for Intravitreal Injections of Eylea and Lucentis. June 2019. bit.ly/HHSOIGInject . Accessed 08/07/19.