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2023 Final Rule Q&A
Recently, BSM's Billing, Coding, and Compliance Division (BCCD) hosted its first Coding Coffee Chat, a live digital forum of The Messenger, to address client questions regarding the 2023 Final Rule as well as a few other topics. With the Final Rule being nearly 3,000 pages and having experienced a late-December adjustment to the Medicare Physician Fee Schedule (MPFS), many had lingering compliance questions. This blog post addresses some of the most common ophthalmology inquiries the BCCD received during the Coding Coffee Chat. If you have additional Final Rule questions, please email CodingandCompliance@bsmconsulting.com.
1. What JZ and JW modifier updates should retina practices be aware of for 2023?
In the 2023 Final Rule, the Centers for Medicare & Medicaid Services (CMS) finalized the new JZ modifier, Zero drug amount discarded/not administered to any patient. Per CMS’s JW and JZ Modifier Policy Frequently Asked Questions (FAQ), practices have until July 1, 2023, to start implementing the new JZ modifier. At that time, all single-dose injectable medications need to have either the JW or JZ modifier appended to the claim. In the same FAQ, CMS further states that claims received on or after Oct. 1, 2023, that do not have the appropriate JW or JZ modifier may be returned as “unprocessable” until the claim is corrected.
We recommend doing a “soft” start now with the JZ modifier. To achieve this, make sure the JZ modifier is added to your Electronic Practice Management (EPM) system and discuss implementation with your billing clearinghouse, if applicable.
More information on the JZ and JW modifier can be found in the January 2023 issue of The Messenger and our “What to Know for 2023” webinar recording. To access these materials, you must login to your BSM Connection account.
2. Do we know if the JW and JZ modifier is going to be an auditing interest?
Considering the dollars involved with drug reimbursement (e.g., Lucentis®, Eylea®), it seems likely. The JW modifier has been scrutinized by CMS, which is part of the reason why the federal agency established the JZ modifier: to help differentiate claims. The same JW and JZ FAQ referenced above states, “Claims that bill for drugs furnished on or after July 1, 2023, that do not report the JW or JZ modifier may be subject to provider audits.”
3. What are the general rules behind using modifier -25 related to retinal injections and medications?
Modifier -25 is defined as a “significant, separately identifiable Evaluation and Management (E/M) service by the same physician … on the same day of the procedure …” In other words, if the patient is being evaluated primarily to determine or confirm the need for an intravitreal injection, modifier -25 is likely not supported. However, if the patient has a new complaint in the contralateral eye warranting an exam, modifier -25 is likely supported.
Minimally Invasive Glaucoma Surgery (MIGS) Coding Questions
1. How should we code and document MIGS concurrently with cataract surgery?
On Jan. 1, 2022, two Category I Current Procedural Terminology (CPT®) codes — 66991 and 66989 — were added to replace the Category III CPT code 0191T. CPT code 66991 describes routine cataract surgery with intraocular lens (IOL) insertion and implantation of an aqueous drainage device, and CPT code 66989 describes complex cataract surgery with IOL insertion and implantation of an aqueous drainage device. The full CPT definitions for 66991 and 66989 are as follows:
- 66991 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
- 66989 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
As with all procedures, documenting medical necessity for both the cataract extraction and glaucoma treatment (MIGS procedures) within the patient’s medical record is key.
2. Can we code 66991 with 65820 in the same session?
Currently, there isn’t a National Correct Coding Initiative (NCCI) edit for CPT codes 66991 and 65820. However, if the surgeon recommends three procedures (e.g., cataract, stent insertion, and goniotomy), the chart documentation should satisfy medical necessity for each procedure. The surgeon must adequately document why the additional MIGS procedure (stent or goniotomy) is medically necessary. Typical “canned language” used in an Electronic Health Record (EHR) for cataract/MIGS cannot be the same for cataract/MIGS/goniotomy.
Currently, Local Coverage Articles (LCAs) from several Medicare Administrative Contractors (MACs), including Noridian and Palmetto discuss the issue by stating:
“Specifically, goniotomy (CPT® code 65820) should not be coded in addition to other angle surgeries, stent insertions or Schlemm canal implants or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure. … Documentation regarding the reasonable and necessary premise for the work must be present. Noridian [or Palmetto GBA] may request additional documentation on a case-by-case basis.”
Complex Cataract Surgery Question
1. We are seeing more complex cataract claim denials for using Trypan Blue only. What has changed with the Local Coverage Determinations (LCDs)?
Most MACs have LCDs and LCAs that address indications for a complex cataract case (66982), such as iris hooks, a sutured IOL, Trypan Blue, etc. It’s important for each practice to review its MAC’s LCDs/LCAs to determine specific coverage.
Although preplanning for a complex case is not a requirement, it may be beneficial to have the preoperative documentation to help achieve medical necessity. The operative report also needs to describe why a device/technique was used not just list the devices used. In other words, the surgeon's operative report should describe what was encountered during surgery and the steps taken to address the issue. For example, a dense mature cataract limiting capsule visualization resulted in the need for Trypan Blue stain to effectively proceed with surgery.
LOOKING FOR CODING AND COMPLIANCE ASSISTANCE? Contact the BCCD at 800-832-0609 or CodingandCompliance@bsmconsulting.com.