In 2011, the American Medical Association created CPT Code 65778 (currently defined as: “Placement of membrane on the ocular surface; without sutures,”) because it recognized the importance of delivering the wound healing properties of amniotic membrane to the ocular surface without the use of sutures. In 2020, use of amniotic membranes is part of most ophthalmic practices’ clinical protocols for corneal problems.
Let’s look at current CPT characteristics and reimbursement for the placement of a non-sutured amniotic membrane on the ocular surface.
CPT Code: 65778
CPT Definition: Placement Of Amniotic Membrane On The Ocular Surface; Without Sutures
CPT Code Status: Active Code. These codes are paid separately under the physician fee schedule, if covered. There will be RVUs for codes with this status. The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.
Bilateral/Unilateral Status: 150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.
Total Non-Facility RVU’s: 39.80
Global Period: 0 Days
2020 CMS National Average Maximum Allowable: $1,436.00
Although CPT references it as a surgical procedure, clinical application of an amniotic membrane device is virtually identical to the insertion of a bandage contact lens, but please take care when coding this procedure or you may make a mistake if you don’t follow the rules on surgical coding. Coding for a minor surgical procedure is not difficult, but it is important to realize that in accordance with minor surgical rules, an office visit (either 920XX or 992XX) is generally not separately billable when performed on the same date of service as CPT code 65778. That’s because reimbursement for the 65778 code itself already includes compensation for the office visit related to the decision to perform this minor surgical procedure. So it would be the rare occasion to append modifier -25 to an E/M office visit performed on the same day as the application of an amniotic membrane.
In January 1, 2016 there was a significant change made to the code - the global period was reduced to zero days from 10 days. What is the impact of this at a practice level? Simple. There is no longer a period of time following the application of an amniotic membrane that is incorporated into the payment. Each follow-up after the application is now a billable procedure based upon the commensurate medical necessity of the encounter. Please take note: This does NOT mean you can bill simply for the removal of the membrane, but you have to meet the requirements and definitions for an office visit just as you would for any follow-up visit whether it be a 9921X or 9201X.
Use of amniotic membranes on the ocular surface is now a well-established route of therapy that can certainly speed up the cycle of healing, particularly for severe inflammatory conditions. With respect to ocular surface disease, amniotic membranes are generally reserved for more advanced disease as you are not treating the “dry eye”, but are treating the corneal sequelae of the OSD so medical necessity for this procedure would generally be established after the failure of lesser methods of treatment.
Please keep in mind that for CMS and most other commercial carriers, charging separately for the supply of the amniotic membrane is not allowed as it’s bundled into the reimbursement for the procedure itself (not unlike the rationale used for punctal plugs) so please don’t bill for V2790 with 65778. Very rarely, other commercial carriers may have policies that allow for reimbursement of the procedure and the materials, and if so, the appropriate HCPCS Level II code is V2790 (“Amniotic membrane for surgical reconstruction, per procedure.”) But my advice here is don’t bill for it as a separate item as a general rule.
Having amniotic membranes as part of your treatment arsenal is a big boon to your practice. Establishing appropriate and proper medical necessity for the procedure is key. Employing technology such as amniotic membranes reminds us of just how far we have come in being able to provide emergent technology in caring for our patients that provide outcomes that we could only dream of a few years ago. Your long-term success will always depend on your ability to properly establish medical necessity, having a meticulous medical record, and following the detailed documentation rules that the CPT, ICD-10 and your carriers require.
PRMI Practice Resource Management, Inc.
Dr. John M. B. Rumpakis
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