Retina specialists are accustomed to integrating new drugs into their clinics. Unfortunately, FDA approval does not guarantee coverage, and reimbursement is often a challenge as payers update their policies. The recent FDA-approved treatments for geographic atrophy (GA) brought with them unique considerations.

The first FDA-approved drug to treat GA was pegcetacoplan (Syfovre, Apellis Pharmaceuticals), followed by avacincaptad pegol (Izervay, Iveric Bio/Astellas Pharma). Reviewing the FDA indications and limitations of each drug helps to understand the guidelines for reimbursement.

GETTING STARTED

The first step to reporting a clean claim to the payer is to confirm that the setup in your practice management system is correct for these new drugs. You can review more details in the AAO’s Coding for Injectable Drugs.1 Next, complete the appropriate documentation. Use the AAO’s Intravitreal Injection Checklist to perform pre-payment reviews.2

Finally, recognize the following four nuances related to GA coding and reimbursement and prepare a strategy to avoid any potential barriers for a more streamlined process.

1. New Drugs Report NOC HCPCS Codes

When a new drug is introduced to a practice, it is initially reported with a not otherwise classified (NOC) Healthcare Common Procedure Coding System (HCPCS) code until a permanent code is assigned. Each payer may have a preferred NOC code during this initial phase, potentially causing claim issues. To further complicate matters, NOC codes require additional information to be reported in item 19 of the CMS-1500 (medication name and dosage), which will affect reimbursement if missing, incomplete, or inaccurate.

Pegcetacoplan was first reported with NOC code J3490 for most payers. Effective July 1, C9151, injection pegcetacoplan 1 mg was reported for facility use, followed by J2781, effective October 1, with the same descriptor for the office setting. Each code is reported with 15 units.

Avacincaptad pegol, FDA-approved in August, is reported with an NOC code per payer preference (J3490, office; C9399, facility) until a permanent code is assigned.

2. ICD-10-CM Codes

When billing for an intravitreal injection (CPT code 67028) for GA, some payers may initially deny the claim due to a lack of policy or coverage for this unique diagnosis and its recently approved treatment. Additionally, there is no specific ICD-10-CM code for GA; it is reported with the ICD-10-CM code for nonexudative AMD, H35.3-, with or without subfoveal involvement. Historically, some payers have flagged intravitreal injection claims that were submitted with a nonexudative AMD ICD-10-CM code to automatically deny reimbursement or for auditing purposes post-payment.

3. Dual Treatment

In the case of a patient with wet AMD and GA in the same eye, the clinician may decide to treat both conditions on the same day, requiring two separate injections, even though only one injection can be paid per encounter. This is due to the medically unlikely edit for CPT code 67028 of 1, which means that this code can be reimbursed once per encounter.

When two injections are performed for two separate indications, reporting the appropriate ICD-10-CM-to-CPT code link on the claim form is essential. The intravitreal injection, CPT code 67028, should be linked to the ICD-10-CM code for GA and the indication for the anti-VEGF therapy. The HCPCS code for the anti-VEGF injection should be linked to the wet AMD and the GA drug linked to the nonexudative AMD ICD-10-CM code. For example, here is how you should code for faricimab-svoa (Vabysmo, Genentech/Roche) and pegcetacoplan injected on the same day in the same eye:

  • 67028-LT; H35.3221, H35.3124; 1 unit
  • J2777; H35.3221; 60 units
  • J2781; H35.3124; 15 units

4. The 28-Day Rule

Many treatments have dosing and administration guidelines based on the FDA label that limit the frequency of injections to no sooner than every 28 days in the same eye. Thus, when an injection of a GA therapy is performed sooner than 28 days of an anti-VEGF injection in the same eye, the payer may incorrectly deny the claim due to frequency issues. Payer policies and claim edits must be adjusted per medication and FDA label, but until updated, clinicians must be prepared for the possibility of initial denials.

BE PROACTIVE, NOT REACTIVE

Clinicians should be prepared to meet any claim denials with an appeal letter establishing medical necessity for the procedure. You can streamline this process by remaining up to date on payer policies, identifying potential reimbursement barriers, educating the billing team, preparing letter templates, and monitoring the accounts receivable.

As you continue to implement new drugs into your practice, refer to the AAO’s retina coding resources at aao.org/retinapm for appropriate HCPCS codes, billing units, indications, and –JW or –JZ modifiers on a drug-by-drug basis.

1. Coding for Injectable Drugs. American Academy of Ophthalmology. Accessed September 19, 2023. bit.ly/3QgvFMJ

2. Checklist: Intravitreal Injections Documentation and Coding Guidelines. American Academy of Ophthalmology. September 2023. Accessed September 19, 2023. bit.ly/45RRAQe