Laser therapy of vitreous floaters was not a topic that I was planning for this issue. However, we continue to get questions about YAG laser for vitreous floaters from both retina specialists and even general ophthalmologists. They ask about coding, coverage and reimbursement. I’ll review those areas here. Note that vitrectomy for vitreous floaters, while coded differently, isn’t part of this discussion, but much of the medical necessity discussion is germane.
Coverage
The question is, “Is this covered by insurance?” Unfortunately, the answer is not so black and white. First, is the procedure medically necessary? In other words, is the floater(s) so significant that it limits vision and/or impedes a person’s ability to perform a function or task? Sometimes the impact is significant, but one article states, “Vitreous opacities are almost universal, and most need no treatment.”1
Consider medical necessity for treating a vitreous floater similar to when a surgeon documents medical necessity for cataract surgery. The surgeon documents how the cataract impacts or impedes activities of daily living (ADLs) and that there’s a high likelihood that removing the cataract will improve or restore those ADLs. We recommend our clients use a questionnaire to score the severity of the floaters and document specific compromised ADLs. A sample questionnaire can be found at www.corcoranccg.com/products/forms/laser-floater-ellex/.
Government and commercial payers have published limited-coverage policies, but there are no published policies from any Medicare Administrative Contractors (MAC). We did find two commercial polices that consider this service non-covered.
Aetna’s medical policy, YAG Laser in Ophthalmology and Other Selected Indications, states: “Aetna considers Nd: YAG laser vitreolysis experimental and investigational for the treatment of vitreous degeneration and vitreous floaters because its effectiveness for these indications has not been established.”2
Florida Blue’s position statement in its laser vitreolysis coverage guideline states: “Laser vitreolysis is considered experimental or investigational, for treatment of all other indications, and specifically vitreous floaters of the eye, as there is insufficient clinical evidence in the published peer-reviewed literature to support effectiveness.”3
Two codes to consider
Like the coverage, the coding isn’t black and white. There are two codes to consider:4
67031—Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages.
67299—Unlisted procedure, posterior segment.
The preference, when filing a claim, is 67031 and avoiding the unlisted code. When a floater is severed and sinks to the bottom of the vitreous and out of the line of sight, CPT 67031 likely applies. In contrast, if the floater is “vaporized,” “destroyed” or fragmented into smaller pieces, the unlisted code, CPT 67299, would apply. Severing is the key term, defined in Merriam-Webster Dictionary as “to remove (something, such as a part) by or as if by cutting.” CPT contains instructions to use an unlisted code when a specific code is unavailable.
If you use CPT 67031, don’t overlook the “one or more stages” designation. This means the surgeon gets one payment for the procedure even if the same laser treatment is repeated during the postoperative period.
Utilization and reimbursement
Within Medicare, these procedures are not performed often. According to the 2017 Medicare paid claims data, CPT 67031 was reimbursed 5,815 times while CPT 67299 was reimbursed 160 times. The 2019 national Medicare Physician Fee Schedule reimbursement rate for 67031 is $400 in the office and $380 in an outside facility. Relative Value Units (RVUs) aren’t assigned to the unlisted code, 67299, so surgeon reimbursement is determined on a case-by-case basis.
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Bottom line
It’s important to consider the medical necessity for laser treatment of vitreous floaters. Without significant symptoms and/or an impact on function, it probably won’t be covered. Ultimately, it’s the physician’s decision to treat the problem, but if the patient insists and medical necessity is lacking, consider using an advanced beneficiary notice of coverage (ABN) or similar waiver for non-Medicare patients. In those cases, the patient is financially responsible for the service. In the same way, if the unlisted code (67299) is used, initiating an ABN or waiver is a good idea because payers often determine coverage for unlisted services after reviewing supporting documentation.
To avoid any coverage dilemmas with patients who have floaters, develop a process to evaluate and document medical necessity and create an ABN or waiver to inform the patients of any financial obligations. Finally, watch the subtle language in the codes; it’s very likely that 67299 will be used for many of these procedures. RS
REFERENCES
1. Karickhoff JR. YAG Laser offers safe option for floaters. Ocular Surgery News. https://www.healio.com/ophthalmology/retina-vitreous/news/print/ocular-surgery-news/%7Be3262a47-4d0d-4231-8613-6d225ab1c4bc%7D/yag-laser-offers-safe-option-for-floaters Updated March 15, 2007. Accessed May 6, 2019.
2. Aetna. Policy Number: 0354. YAG Laser in Ophthalmology: Selected Indications. Last reviewed 04/10/2019. http://www.aetna.com/cpb/medical/data/300_399/0354.html#dummyLink1. Accessed April 14, 2019.
3. Blue Cross/Blue Shield of Florida. Medical Coverage Guidelines: Laser vitreolysis. Revised May 11, 2014. http://mcgs.bcbsfl.com/MCG?activity=openSearchedDocMcg&imgId=75IW0HRF53QMSGPV4HT. Accessed April 14, 2019.
4. CPT 2019 (CPT/Current Procedural Terminology (Professional Edition). Chicago, IL; American Medical Association; 2019.
