1. Coding for High Risk Meds (eg, Plaquenil)

2. Coding for High Risk Meds
Office visit, 92 or 99
ICD examples:
Toxic maculopathy. Use E code of drug.
Anterior pigmentations
Lupus erythematosus
Systemic lupus erythematosus
Rheumatoid arthritis

3. Coding for High Risk Meds
ICD examples:
V Long term (current) use of other medications
V Encounter for therapeutic drug monitoring
V Following completed treatment with high-risk
medication
(After medication stopped, visits look for latent toxicity)
V Special screening

4. Coding for High Risk Meds
Office visit - Frequency
-As medically indicated, dose-dependent. (q 3mo, 6mo, 12mo)
-No limit on office visits.
-Manage separate from routine vision care.

5. Coding for High Risk Meds
2011 Plaquenil Screening Tests
(Am.Acad.Ophthal.)
Extended Ophthalmoscopy
Fundus Photography
Visual Field
Scanning Imaging, FAF, or mfERG

6. Coding for High Risk Meds
Extended Ophthalmoscopy
-Should not be used as screening test alone, due to low sensitivity. (AAO)

7. Coding for High Risk Meds
Extended Ophthalmoscopy
Toxic maculopathy, often paid. Use E code for drug.

8. Coding for High Risk Meds
Fundus Photography
-Not sensitive enough to identify early findings associated with retinal toxicity. (AAO)

9. Coding for High Risk Meds
Fundus Photography - ICD examples
Toxic maculopathy. Use E code for drug
Systemic lupus erythematosus
V Long term (current) use of other medications

10. Coding for High Risk Meds
Visual Field
-Loss in paracentral retina may be 1st sign of toxicity. (AAO)
-Paracentral defects indicate abnormality before RPE changes visible. (AAO)

11. Coding for High Risk Meds
Visual Field – ICD examples often paid
Toxic maculopathy. Use E code for drug
Anterior pigmentation
V58.69 Long term (current) use of other
medications
V Encounter for therapeutic drug
monitoring;
V Long term (current) use of other

12. Coding for High Risk Meds
Scanning Imaging, FAF, or mfERG
Testing should include at least one of these 3.  (AAO)

13. Coding for High Risk Meds
1) SD-OCT (retina)
Early change may reflect macular thinning,
disruption at photoreception integrity line or inner/outer segment layer. (AAO)
ICD, often paid
Toxic maculopathy. Use E code for drug.

14. Coding for High Risk Meds
1) SD-OCT (retina)
A baseline study of optic nerve and retinal imaging is considered medically necessary before initiation of chloroquine, hydroxychloroquine. Aetna Clinical Policy

15. Coding for High Risk Meds
1) SD-OCT (retina)
Nine Medicare Part B contractors: 6 approve V58.69 (Novitas, CGS, First Coast, NGS, NHIC, WPS).
Three contractors (Cahaba, Noridan, Palmetto) are silent about V58.69 – no LCD for OCT.

16. Coding for High Risk Meds
1) SD-OCT (retina)
States with Cahaba, Noridan, Palmetto:
If with V58.69 is denied (as in past), submit appeal, giving evidence that Novitas, CGS, First Coast, NGS, NHIC, WPS pay for V58.69.
Chances are good the contractor will reverse its decision and it will be paid.

17. Coding for High Risk Meds
2) FAF: (retina) or 92250
“Fundus AutoFluorescence”
-Early RPE defect damage shows reduction of autofluorescence. (AAO)
-Photoreceptor damage shows increase of autofluorescence. (AAO)
ICD, may be paid
Toxic maculopathy. Use E code for drug

18. Coding for High Risk Meds
3) mfERG
Multi-Focal Electroretinography,
Objectively documents paracentral functional damage. (AAO)
ICD, may be paid
Toxic maculopathy. Use E code for drug

19. Coding for High Risk Meds
Secondary ICD Code, ie, “E” Code
Example:
E Antimalarials and drugs acting on other blood protozoa

20. Thank You! Evaluations Questions
You Made It!
Thank You! Evaluations Questions