Article - Billing and Coding: Intraocular Bevacizumab (A53008)

CMS National Coverage PolicyN/AArticle TextBevacizumab is not currently packaged and prepared by the manufacturer in doses appropriate for intravitreal injection. Physicians routinely obtain single doses prepared by qualified compounding pharmacies to minimize risk of contamination of the injected drug.Noridian previously considered such use as an "unclassified biologic" and has required claims to reflect HCPCS J3590. The use of HCPCS J7999 will allow for better tracking and recall should a problem arise with a compounded drug. The use of J7999 is not restricted to bevacizumab and shall be used for all compounded injectable drugs.Effective January 1, 2016 Noridian requires that, when billing intravitreal bevacizumab acquired from a compounding source or compounded in the physicians facility/office, the new HCPCS code J7999 be used on the claims submission.Beginning January 1, 2016 claims for compounded bevacizumab for intravitreal use submitted with the HCPCS J3590 will be returned as a billing error.For Part B claims, enter "Intravitreal bevacizumab, [dose] mg" in Item 19 of CMS-1500 claim form or in Loop 2300 or 2400, NTE, 02 for electronic claims.For Part A claims, use HCPCS code C9257. Provide the number of units.When billing CPT code 67028, modifiers RT or LT must be used to indicate the eye treated. When billing bilateral, use modifier 50.When billing J7999, enter '1' in the days/unit field for one eye, or "2" in the days/unit field if both eyes must be treated in the same encounter.The use of scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) (CPT 92134) is appropriate at four-six week intervals to help evaluate the need for re-treatment. Use of both scanning laser and fundus photography, which are bundled under the NCCI, requires appropriate documentation of medical necessity.Consistent with the statement of April 2006 of the American Academy of Ophthalmology (AAO) in support of this use of bevacizumab, physicians should provide appropriate informed consent with respect to the off-label use of this drug and maintain it in the patient chart. As always, medical records are subject to post-pay review and must be submitted to Noridian or other Medicare authorized agency, if requested.Current scientific literature published in the peer-reviewed core medical journals supports these uses of this drug. The published experience shows that patients with wet macular degeneration may require regular injections for up to a year if new vessels appear and many may require injections even longer. The most recent clinical trial data now extends out beyond five years and demonstrates that most patients continue to require treatment beyond two years.If and as literature and/or specialty society recommendations warrant, we will add additional covered codes while possibly removing others from this list. Because of the likelihood that frequent changes will be necessary, wedo notplan to incorporate this issue into a Local Coverage Determination (LCD).With regard to the treatment of "wet" macular degeneration, consistent with the NIH-sponsored Comparison of Age-related macular degeneration Treatment Trial (CATT), treatment more frequently than approximately every four weeks (in a given eye) would be expected to be very rare and require explicit documentation justifying that use.With regard to other diagnoses, we anticipate the frequency of administration would be supported by current available literature.