Each year, there are coding changes that impact the retina practice. Along with identifying these updates, it is crucial to ensure practice resources are revised accordingly and the entire team is on the same page. Here, I highlight five changes you need to be ready to handle this year.

1. NEW CATEGORY 1 CPT CODE

New to CPT in 2024 is Category I code, 67516, suprachoroidal space injection of pharmacologic agent (separate procedure), which replaced the deleted Category III code, 0465T.

For example, an injection of triamcinolone acetonide (Xipere, Bausch + Lomb and Clearside Biomedical) into the suprachoroidal space is performed in the left eye, with 4 mg/0.1 mL injected and 32 mg/0.8 mL discarded. The correct coding for this case is as follows:

  • 67516–LT
  • J3299, 4 units
  • J3299–JW, 32 units

2. NEW CATEGORY III CODE

Effective July 1, 2023, a new Category III code was added, 0810T, subretinal injection of a pharmacologic agent, including vitrectomy and one or more retinotomies.

For example, a subretinal injection of voretigene neparvovec-rzyl (Luxturna, Spark Therapeutics), pars plana vitrectomy, and retinotomy is performed in the right eye at an ambulatory surgery center. The physician would report 0810T, and the facility would bill the facility fee and drug.

3. NEW DRUG TREATMENTS

A permanent HCPCS code, J2781, was assigned for 1 mg pegcetacoplan intravitreal injection (Syfovre, Apellis Pharmaceuticals), effective October 1, 2023, for the treatment of geographic atrophy. This new code should be reported in both the office and facility setting, as the previous facility code, C9151, was deleted as of September 30, 2023.

For example, an intravitreal injection of 15 mg/0.1 mL pegcetacoplan is performed in the right eye. Residual medication (overfill) less than 1 unit was discarded. The correct coding for this case is as follows:

  • 67028–RT
  • J2781–JZ, 15 units

Another drug treatment for geographic atrophy was FDA approved last summer, avacincaptad pegol intravitreal solution (Izervay, Iveric Bio/Astellas). As a new drug treatment, it should be reported with a not otherwise classified (NOC) HCPCS until a permanent code is assigned.

For example, an intravitreal injection of avacincaptad pegol is performed in the left eye. Residual medication (overfill) less than 1 unit was discarded. The correct coding in this case is as follows:

  • 67028–LT
  • J3490–JZ, 1 unit
  • Report in item 19 of the CMS-1500 the method of administration, medication name, and dosage as intravitreal injection of 2 mg/0.1 mL avacincaptad pegol

Also new to the retina practice is the recently FDA approved 8 mg aflibercept (Eylea HD, Regeneron). This new drug should also be billed with an NOC code until the permanent code is assigned in the near future. For updates to all new retina drugs, visit aao.org/retinapm.

4. ICD-10-CM CODES FOR SICKLE CELL RETINOPATHY

Both nonproliferative and proliferative sickle cell retinopathy now have specific ICD-10-CM codes to report these conditions. Previously, this disease was billed with unspecified codes. Effective October 1, 2023, report with the following codes:

  • H36.811: Nonproliferative sickle cell retinopathy, right eye
  • H36.812: Nonproliferative sickle cell retinopathy, left eye
  • H36.813: Nonproliferative sickle cell retinopathy, bilateral
  • H36.821: Proliferative sickle cell retinopathy, right eye
  • H36.822: Proliferative sickle cell retinopathy, left eye 
  • H36.823: Proliferative sickle cell retinopathy, bilateral

For example, an intravitreal injection of 1.25 mg/0.05 mL bevacizumab (Avastin, Genentech/Roche) is performed in the right eye of a patient with nonproliferative sickle cell retinopathy on Medicare Part B. The Medicare Administrative Contractor for this patient is Noridian, which updated its local coverage article (LCA) A53008 effective October 1, 2023, with the new ICD-10-CM codes, payable for intravitreal injections. The correct coding for this case is as follows:

  • 67028–RT
  • *J7999–JZ, 1 unit
  • Report in item 19 of the CMS-1500 the method of administration, medication name, and dosage as intravitreal injection of 1.25 mg/0.05 mL bevacizumab
  • ICD-10-CM code linked to both 67028 and J7999, H36.811

*Note: HCPCS code J7999 should be reported for bevacizumab for ophthalmic use per Noridian’s LCA. For other payers, confirm the appropriate HCPCS code per their unique policies.

5. MODIFICATION OF E/M CODE DESCRIPTORS

A slight update has been made to the E/M office visit family of codes related to the criteria when coding based on total physician time on the date of the encounter (Table). For 2024, the amount of time for each code must meet or exceed the designated amount. Previously, there was a range. This revision is meant to streamline the selection process.

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For example, the descriptor for CPT code 99203 is “office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.” From 2021 to 2023, when using time for code selection, 30 to 44 minutes of total time must have been spent on the date of the encounter. In 2024, when using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

STAY CONNECTED

With new drug treatments on the horizon and payer policies constantly being updated, clinicians must stay vigilant with their coding knowledge. Access current AAO resources on the Retina Practice Management and Coding webpage at www.aao.org/practice-management/coding/retina.