Coding for High Risk Meds (eg, Plaquenil)

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

2. Coding for High Risk Meds Office visit, 92 or 99 ICD examples: 362.55 Toxic maculopathy. Use E code of drug. 371.11 Anterior pigmentations 695.4 Lupus erythematosus 710.0 Systemic lupus erythematosus 714.0 Rheumatoid arthritis

3. Coding for High Risk Meds ICD examples: V58.69 Long term (current) use of other medications V58.83 Encounter for therapeutic drug monitoring V67.51 Following completed treatment with high-risk medication (After medication stopped, visits look for latent toxicity) V80.2 Special screening

4. Coding for High Risk Meds Office visit - Frequency -As medically indicated, dose-dependent. (q 3mo, 6mo, 12mo) -No limit on office visits. -Manage separate from routine vision care.

5. Coding for High Risk Meds 2011 Plaquenil Screening Tests (Am.Acad.Ophthal.) Extended Ophthalmoscopy Fundus Photography Visual Field Scanning Imaging, FAF, or mfERG

6. Coding for High Risk Meds Extended Ophthalmoscopy -Should not be used as screening test alone, due to low sensitivity. (AAO)

7. Coding for High Risk Meds Extended Ophthalmoscopy -362.55 Toxic maculopathy, often paid. Use E code for drug.

8. Coding for High Risk Meds Fundus Photography -Not sensitive enough to identify early findings associated with retinal toxicity. (AAO)

9. Coding for High Risk Meds Fundus Photography - ICD examples 362.55 Toxic maculopathy. Use E code for drug 710.0 Systemic lupus erythematosus V58.69 Long term (current) use of other medications

10. Coding for High Risk Meds Visual Field - 10-2 -Loss in paracentral retina may be 1st sign of toxicity. (AAO) -Paracentral defects indicate abnormality before RPE changes visible. (AAO)

11. Coding for High Risk Meds Visual Field – ICDexamples often paid 362.55 Toxic maculopathy. Use E code for drug 371.11 Anterior pigmentation V58.69 Long term (current) use of other medications V58.83 Encounter for therapeutic drug monitoring; V58.69 Long term (current) use of other medications

12. Coding for High Risk Meds Scanning Imaging, FAF, or mfERG Testing should include at least one of these 3.  (AAO)

13. Coding for High Risk Meds 1) SD-OCT 92134 (retina) Early change may reflect macular thinning, disruption at photoreception integrity line or inner/outer segment layer. (AAO) ICD, often paid 362.55 Toxic maculopathy. Use E code for drug.

14. Coding for High Risk Meds 1) SD-OCT 92134 (retina) • A baseline study of optic nerve and retinal imaging is considered medically necessary before initiation of chloroquine, hydroxychloroquine. Aetna Clinical Policy

15. Coding for High Risk Meds 1) SD-OCT 92134 (retina) Nine Medicare Part B contractors: 6 approve V58.69 (Novitas, CGS, First Coast, NGS, NHIC, WPS). Three contractors (Cahaba, Noridan, Palmetto) are silent about V58.69 – no LCD for OCT.

16. Coding for High Risk Meds 1) SD-OCT 92134 (retina) States with Cahaba, Noridan, Palmetto: If 92134 with V58.69 is denied (as in past), submit appeal, giving evidence that Novitas, CGS, First Coast, NGS, NHIC, WPS pay for V58.69. Chances are good the contractor will reverse its decision and it will be paid.

17. Coding for High Risk Meds 2) FAF:92134(retina) or 92250 “Fundus AutoFluorescence” -Early RPE defect damage shows reduction of autofluorescence. (AAO) -Photoreceptor damage shows increase of autofluorescence. (AAO) ICD, may be paid 362.55 Toxic maculopathy. Use E code for drug

18. Coding for High Risk Meds 3) mfERG Multi-Focal Electroretinography, 92275. Objectively documents paracentral functional damage. (AAO) ICD, may be paid 362.55 Toxic maculopathy. Use E code for drug

19. Coding for High Risk Meds Secondary ICD Code, ie, “E” Code Example: E931.4 Antimalarials and drugs acting on other blood protozoa

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