Coding for High Risk Meds (eg, Plaquenil) 1. Coding for High Risk Meds Office visit, 92 or 99 ICD examples: 362.55 Toxic maculopathy. Use E code of drug

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

11

Coding for High Risk Meds Coding for High Risk Meds

Office visit, 92 or 99Office visit, 92 or 99

ICD ICD examples:examples:362.55 Toxic maculopathy. Use E code of drug.362.55 Toxic maculopathy. Use E code of drug.

371.11 Anterior pigmentations 371.11 Anterior pigmentations

695.4695.4 Lupus erythematosus Lupus erythematosus

710.0 Systemic lupus erythematosus710.0 Systemic lupus erythematosus

714.0714.0 Rheumatoid arthritis Rheumatoid arthritis

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ICD ICD examples:examples:V58.69 Long term (current) use of other V58.69 Long term (current) use of other

medicationsmedications

V58.83 Encounter for therapeutic drug monitoringV58.83 Encounter for therapeutic drug monitoring

V67.51 Following completed treatment with high-V67.51 Following completed treatment with high-risk risk

medicationmedication

(After medication stopped, visits look for latent (After medication stopped, visits look for latent toxicity)toxicity)

V80.2 Special screeningV80.2 Special screening33


Office visit - FrequencyOffice visit - Frequency-As medically indicated, dose-dependent. -As medically indicated, dose-dependent. (q (q

3mo, 6mo, 12mo)3mo, 6mo, 12mo)

-No limit on office visits.-No limit on office visits.

--Manage separate from routine vision care.Manage separate from routine vision care.

44

Coding for High Risk MedsCoding for High Risk Meds

2011 Plaquenil Screening Tests2011 Plaquenil Screening Tests

(Am.Acad.Ophthal.)(Am.Acad.Ophthal.)

Extended Ophthalmoscopy Extended Ophthalmoscopy

Fundus PhotographyFundus Photography

Visual FieldVisual Field

Scanning Imaging, FAF, or mfERGScanning Imaging, FAF, or mfERG

55



-Should not be used as screening test -Should not be used as screening test alone, due to low sensitivity. alone, due to low sensitivity. (AAO)(AAO)

66



-362.55 Toxic maculopathy, often paid. Use -362.55 Toxic maculopathy, often paid. Use E code for drug.E code for drug.

77


Fundus PhotographyFundus Photography

-Not sensitive enough to identify early -Not sensitive enough to identify early findings associated with retinal toxicity. findings associated with retinal toxicity. (AAO)(AAO)

88


Fundus Photography - ICDFundus Photography - ICD examples examples

362.55 Toxic maculopathy. Use E code for 362.55 Toxic maculopathy. Use E code for drugdrug

710.0 Systemic lupus erythematosus710.0 Systemic lupus erythematosus

V58.69 Long term (current) use of other V58.69 Long term (current) use of other medicationsmedications

99


Visual Field - 10-2 Visual Field - 10-2

-Loss in paracentral retina may be -Loss in paracentral retina may be 1st sign1st sign of toxicity. of toxicity. (AAO)(AAO)

-Paracentral defects indicate abnormality -Paracentral defects indicate abnormality before RPE changes visible. before RPE changes visible. (AAO)(AAO)

1010


Visual Field – ICDVisual Field – ICD examples often paidexamples often paid

362.55 Toxic maculopathy. Use E code for drug362.55 Toxic maculopathy. Use E code for drug

371.11 Anterior pigmentation371.11 Anterior pigmentation

V58.69 Long term (current) use of other V58.69 Long term (current) use of other


V58.83 Encounter for therapeutic drug V58.83 Encounter for therapeutic drug

monitoring; monitoring;

V58.69 Long term (current) use of other V58.69 Long term (current) use of other


1111


Scanning Imaging, FAF, or mfERGScanning Imaging, FAF, or mfERG

Testing should include at least one of these Testing should include at least one of these 3. 3. (AAO) (AAO)

1212


1) SD-OCT 921341) SD-OCT 92134 (retina) (retina)

Early change may reflect macular thinning, Early change may reflect macular thinning, disruption at photoreception integrity line disruption at photoreception integrity line

or inner/outer segment layer. or inner/outer segment layer. (AAO)(AAO)

ICD, ICD, often paidoften paid

362.55 Toxic maculopathy. Use E code for 362.55 Toxic maculopathy. Use E code for drug.drug.

1313



A baseline study of optic nerve and A baseline study of optic nerve and

retinal imaging is considered medically retinal imaging is considered medically necessary before initiation of chloroquine, necessary before initiation of chloroquine, hydroxychloroquinehydroxychloroquine.. Aetna Clinical Policy Aetna Clinical Policy

1414



Nine Medicare Part B contractors: 6 Nine Medicare Part B contractors: 6 approve V58.69 (Novitas, CGS, First Coast, approve V58.69 (Novitas, CGS, First Coast, NGS, NHIC, WPS). NGS, NHIC, WPS).

Three contractors (Cahaba, Noridan, Three contractors (Cahaba, Noridan, Palmetto) are silent about V58.69 – no LCD Palmetto) are silent about V58.69 – no LCD for OCT. for OCT.

1515



States with Cahaba, Noridan, Palmetto: States with Cahaba, Noridan, Palmetto:

If 92134 with V58.69 is denied (as in past), If 92134 with V58.69 is denied (as in past), submit appeal, giving evidence that submit appeal, giving evidence that Novitas, CGS, First Coast, NGS, NHIC, WPS Novitas, CGS, First Coast, NGS, NHIC, WPS pay for V58.69. pay for V58.69.

Chances are good the contractor will Chances are good the contractor will reverse its decision and it will be paid.reverse its decision and it will be paid.

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2) FAF:2) FAF: 9213492134 (retina)(retina) or or 9225092250

““Fundus AutoFluorescence”Fundus AutoFluorescence”

-Early RPE defect damage shows reduction of -Early RPE defect damage shows reduction of autofluorescence. autofluorescence. (AAO)(AAO)

-Photoreceptor damage shows increase of -Photoreceptor damage shows increase of autofluorescence. autofluorescence. (AAO)(AAO)

ICD, ICD, may be paidmay be paid


1717


3) mfERG3) mfERGMulti-Focal Electroretinography, 92275. Multi-Focal Electroretinography, 92275.

Objectively documents paracentral functional Objectively documents paracentral functional damage. damage. (AAO)(AAO)

ICD, ICD, may be paidmay be paid


1818


Secondary ICD Code, Secondary ICD Code, ie,ie, “E” Code “E” Code

Example:Example:

E931.4 Antimalarials and drugs acting on other E931.4 Antimalarials and drugs acting on other blood protozoablood protozoa

1919

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Thank You!Thank You!

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2020

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Coding for High Risk Meds (eg, Plaquenil) 1. Coding for High Risk Meds Office visit, 92 or 99 ICD examples: 362.55 Toxic maculopathy. Use E code of drug