Coding

Medications Associated with Intravitreal Injections

Properly document each vial to keep your practice out of hot water.

By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA

As noted in the last issue, the most common ophthalmic procedure in Medicare is intravitreal injection (CPT code 67028). The injection is usually associated with a medication, which may be reimbursable. Some medications are very expensive while others are compounded and considerably less pricey. All have high utilization so they place huge cost burdens on our health care system. Additionally, the Office of the Inspector General has placed oversight that affects these medications in their annual Work Plan. With this amount of focus, it’s easy to see why getting all of the points in this article right is important.

One Package, One Eye

First, each manufacturer places more in the vial than you actually need to ensure a proper dose. That extra is known as “overfill.” Your chart or operative note should demonstrate that the vial has not been “split” (used on multiple patients) by making a note that you expressed – disposed of this – overfill. The temptation is huge to want to use this overfill. It’s against our nature to waste expensive product. Try adding language to your op note to stress the importance of following that guideline. Manufacturers clearly note they require disposal of all excess (unused “overfill”) in their FDA-approved package inserts.

Keep Track

Second, mark each lot, serial, and other specific identifying number for each vial and organize your notes so you can track those numbers to individual eyes. That means having an accurate injection log and process. When there are multiple offices, be sure this is noted in your master log or keep separate ones for each site. In most offices, keeping the log accurate and up to date is the responsibility of the personnel involved with the injections. Of particular note, you might need the log if an error turns up, or worse, an allegation from a payer that might be related (directly or indirectly) to poor record keeping.

Third, keep those purchase records in some form for these expensive drugs since they “indirectly” support the claims that you received and paid for the medication. Reconcile these on a regular basis against your injection log. Investigate all discrepancies; matches must be perfect. Commercial programs can automate this record-keeping process or you can do it on your own; the important piece is that you actually do it.

Complimentary Vials

Finally, don’t forget some vials are provided by manufacturers at no charge; these are not billable to any payer since you incurred no cost. When provided at reduced cost, you can’t ask for the “usual” payment. You would still need these to appear in your op notes, logs, and complementary records to be able to reconcile properly.

Having good records and documentation is the single most important item should you need to support any claims (civil, regulatory, and monetary) against your physicians in the future. Review the documents you have, make changes where you need to and don’t forget to periodically review or revise them.

“Good coding” to all of you! OP

Mr. Larson is an associate consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.