Skip to Main Content

Print | Bookmark | Font Size: + | –

July 14, 2014

Claims Submission Requirements for Ocular Photodynamic Therapy (OPT) with Verteporfin: Services on Professional and Outpatient Hospital Facility Claims

CMS claim processing instructions:

  • CPT code 67221 and67225 must be submitted on the same claim with the drug (HCPCS code J3396) Injection, Verteporfin, 0.1 mg for the same date of service.
  • For place of service office (11):
    • The OPT service (CPT code 67221 or 67225) must be submitted on the same claim as the drug (HCPCS code J3396) for the same date of service.
  • For place of service hospital outpatient (22):
    • The OPT service (CPT code 67221 or 67225) must be submitted on the same date of service as the drug (HCPCS code J3396).
    • When the drug is being submitted for Part A reimbursement (i.e., on the UB-04 form or electronic equivalent), the drug must be shown in the appropriated note field of your electronic claim record as:
      • J3396 Verteporfin was administered on ____________ (enter date of service)
  • OPT with Verteporfin is a covered service when submitted with ICD-9-CM code 362.52 (Exudative Senile Macular Degeneration of Retina (Wet)) (or, when ICD-10-CM codes are required, ICD-10 code H35.32 (Exudative Age-related Macular Degeneration)).
  • Coverage is denied when submitted with either ICD-9-CM code 362.50 (Macular Degeneration (Senile), Unspecified) or 362.51 (Non-exudative Senile Macular Degeneration) or , when ICD-10-CM codes are required, their equivalent ICD-10-CM code H35.30 (Unspecified Macular Degeneration) or H35.31 (Non-exudative Age-Related Macular Degeneration

Reference:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved