Bevacizumab (Avastin®) – Medicare Part B Coding for Off-Label Ophthalmic Use Updated April 2014 Carriers Subject to Change – www.aao.org/coding Medicare Carrier Part B Cahaba GBA www.cahabagba.com Alabama, Georgia, Tennessee HCPCS Code OFFICE J9035 Injection, Bevacizumab, 10 MG L30555 FACILITY C9257 Injection, Bevacizumab, 0.25 MG First Coast Service Options http://medicare.fcso.com Florida, Puerto Rico, US Virgin Islands L29959, L29961 Avastin Coding J3490 OR C9257 Units 1 OR 5 1 ICD-9 Codes that Support Medical Necessity 115.92 Histoplasmosis retinitis unspecified 362.02 Proliferative diabetic retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema 362.16 Retinal neovascularization NOS 362.35 Central retinal vein occlusion 362.36 Venous tributary (branch) occlusion of retina 362.52 Exudative senile macular degeneration of retina 362.53 Cystoid macular degeneration of retina 363.43 Angioid streaks of choroid 365.63 Glaucoma associated with vascular disorders of eye Instructions Office J9035 – use 1 unit Facility C9257– use 5 units 362.02 Proliferative diabetic retinopathy 362.07*Diabetic macular edema 362.16 Retinal neovascularization NOS 362.29 Other nondiabetic proliferative retinopathy 362.35 Central retinal vein occlusion 362.36 Venous tribulary (branch) occlusion of retina 362.52 Exudative senile macular degeneration of retina Current literature indicates anticipated dosage is 1.25 mg (0.05ml) or less, on a yearly average of every 4 to 6 weeks, as needed, by aseptic intravitreal injection into affected eye. Treatment continues on a Off-label use: A. Neovascular (wet) age-related macular degeneration B. Diabetic macular edema; C. Central retinal vein occlusion; D. Venous tributary (branch) occlusion; E. Histoplasmosis retinitis; F. Proliferative diabetic retinopathy; G. Severe nonproliferative diabetic retinopathy; H. Retinal neovascularization; I. Cystoid macular degeneration; J. Angloid streaks of choroid; and K. Glaucoma associated with vascular disorders Page 1 Bevacizumab (Avastin®) – Medicare Part B Coding for Off-Label Ophthalmic Use Updated April 2014 Carriers Subject to Change – www.aao.org/coding 362.53 Cystoid macular degeneration of retina 362.83 Retinal edema 364.42 Rubeosis iridis 365.63 Glaucoma associated with vascular disorders of eye *Per the ICD-9-CM coding manual, ICD-9 code 362.07 requires a dual diagnosis. ICD-9 code 362.07 must be used with a code for diabetic retinopathy (ICD-9 codes 362.01362.06). Novitas Medicare Services www.novitas-solutions.com Effective August 13, 2012 Jurisdiction L: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia: Arlington and Fairfax counties only Jurisdiction H: Arkansas, Louisiana, Mississippi, Texas, Oklahoma, New Mexico, Colorado J9035 or C9257 1 ICD-9 Codes that Support Medical Necessity: N/A ICD-9 Codes that DO NOT Support Medical Necessity: N/A J9035 or C9257 1 362.02 Proliferative diabetic retinopathy 362.07*Diabetic macular edema 362.16 Retinal neovascularization NOS 362.35 Central retinal vein occlusion 362.36 Venous tributary (branch) occlusion of retina monthly basis until the abonormal neovascularization, vitreous hemorrhage, macular edema, subretinal fluid, and/or pigment epithelial detachment is resolved. For more info visit LCD: L29959 L29961 When billing in the nonoutpatient hospital setting: For bevacizumab, providers should use the HCPCS code J9035 (Injection, bevacizumab, 10 mg.), and bill for one unit (10 mg.). When billing in the hospital outpatient setting: For bevacizumab, providers should use HCPCS code C9257 (Injection, bevacizumab, 0.25 mg). A49034 National Government Services www.ngsmedicare.com Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont Avastin Coding Ophthalmologic Indications: Age-related macular degeneration, secondary to choroidal neovascularization; Diabetic macular edema; Page 2 Bevacizumab (Avastin®) – Medicare Part B Coding for Off-Label Ophthalmic Use A46095/L25820 Avastin Coding Updated April 2014 Carriers Subject to Change – www.aao.org/coding 362.52 Exudative senile macular degeneration of retina 362.53 Cystoid macular degeneration of retina 362.83 Retinal edema 364.42 Rubeosis iridis 365.63 Glaucoma associated with vascular disorders of eye *Use of ICD-9-CM code 362.07 – diabetic macular edema is subject to additional coding requirements according to the ICD-9-CM code book. Macular retinal edema, due to retinal vein occlusion; Proliferative diabetic retinopathy. Indications expanded by this Article: Rubeosis and neovascular glaucoma * Report modifier RT or LT with HCPCS code J3590 as appropriate. The actual dose given and the amount of wastage must be documented in the medical record. *Include "bevacizumab or Avastin™," and the dose in Item 19 of the CMS-1500 claim form or its electronic equivalent. The dosage of the drug must be billed as one unit for each eye and not as the volume of the diluted drug administered. The milligrams (e.g., 1.25 mg or 0.25mg) should be entered into item #19 of the CMS-1500 form or its electronic equivalent. *The claim for the intravitreal injection should be coded using CPT code 67028. The appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed Page 3 Bevacizumab (Avastin®) – Medicare Part B Coding for Off-Label Ophthalmic Use Updated April 2014 Carriers Subject to Change – www.aao.org/coding Medicare Carrier Part B Noridian Administrative Services www.noridianmedicare.com Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming A51786 Avastin Coding HCPCS Code J3590 or C9257 Units 1 ICD-9 Codes that Support Medical Necessity 362.01 Background diabetic retinopathy 362.02 Proliferative diabetic retinopathy 362.03 Nonproliferative diabetic retinopathy, NOS 362.04 Mild nonproliferative diabetic retinopathy 362.05 Moderate nonproliferative diabetic retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema 362.15 Retinal telangiectasia 362.16* Retinal neovascularization NOS (choroidal, subretinal) 362.29 Other nondiabetic proliferative retinopathy 362.30 Retinal vascular occlusion, unspecified 362.35 Central retinal vein occlusion 362.36 Venous tributary (branch) occlusion 362.52 Exudative (wet) senile macular degeneration 362.53 Cystoid macular degeneration (cystoid macular edema) 362.83 Retinal edema 362.84 Retinal ischemia 364.42 Rubeosis iridis (neovascularization of iris or ciliary body) 365.63 Glaucoma associated with vascular disorders (e.g, neovascular glaucoma) 365.89 Other specified glaucoma *Requires secondary code describing cause: 115.02 Infection by Histoplasma capsulatum retinitis unilaterally or bilaterally. Claims without a modifier will be returned to the provider unprocessed. Instructions Please see CMS Article A51786 for important instructions. Noridian Alert Feb. 27, 2014 Page 4 Bevacizumab (Avastin®) – Medicare Part B Coding for Off-Label Ophthalmic Use Medicare Carrier Part B Wisconsin Physician Service Insurance Corporation (WPS) www.wps.medicare.com Indiana, Iowa, Kansas, Michigan, Missouri, Nebraska L32013 Avastin Coding Updated April 2014 Carriers Subject to Change – www.aao.org/coding 115.12 Infection by Histoplasma duboisii retinitis 115.92 Histoplasmosis retinitis, unspecified 360.21 Progressive high (degenerative) myopia HCPCS Code Units ICD-9 Codes that Support Medical Necessity J3590 1 362.02 Proliferative diabetic retinopathy Or 362.07 Diabetic macular edema C9257 362.35 Central retinal vein occlusion 362.36 Venous tributary (branch) occlusion 364.42 Rubeosis iridis 362.52 "wet" macular degeneration 362.53 Cystoid macular degeneration 365.63 Glaucoma associated vascular disorders 362.16 Retinal neovascularization-choroidal 362.83 Macular edema Instructions J3590 Bevacizumab (Avastin TM) 1-3 mg- (Use for administration in the office setting) C9257 Bevaciumab 0.25 mg (For hospital outpatient and ASC settings) For important billing guidelines see LCD L32013 Page 5