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Don’t Forget Those Pass-Throughs!

Don’t Forget Those Pass-Throughs!

by Sandy Macica, MS, RHIA, CCS

While ICD-10-CM/PCS changes typically only come out once a year, the Healthcare Common Procedure Coding System (HCPCS) often releases codes and reimbursement changes on a quarterly basis. The HCPCS Quarterly Update for July 1, 2018 brought us some new C, G and other codes that are eligible for pass through or other payments. One C code (C9032) in particular, for a new type of gene therapy, is pretty significant with a reimbursement rate of over $3,000.

Voretigene neparvovec-rzyl or LUXTURNA is indicated for the treatment of patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy. This gene therapy is used to treat children and adult patients with this inherited form of vision loss. There are approximately 1,000 to 3,000 patients with biallelic RPE65 mutation-associated retinal dystrophy in the United States. This loss of vision, often during childhood or adolescence, ultimately progresses to complete blindness.

LUXTURNA works by delivering a normal copy of the RPE65 gene directly to retinal cells. The patients must have viable retinal cells for LUXTURNA to work. These retinal cells then produce the normal protein that converts light to an electrical signal in the retina to restore patient’s vision loss. Treatment must be done separately in each eye on separate days, with at least six days between surgical procedures. It is administered via subretinal injection by a surgeon experienced in performing intraocular surgery. Patients should be treated with a short course of oral prednisone to limit the potential immune reaction to LUXTURNA.

Diagnosis codes that may be applicable to a patient with confirmed biallelic RPE65 mutation-associated retinal dystrophy are:

  • H35.50 Unspecified hereditary retinal dystrophy
  • H35.52 Pigmentary retinal dystrophy
  • H35.54 Dystrophies primarily involving the retinal pigment epithelium

Possible CPT® codes to report the administration of LUXTURNA may include the code for a vitrectomy (67036) or an unlisted procedure, posterior segment (67299). Modifiers should be included to identify the eye to which the administration of LUXTURNA occurred.

Currently this treatment is provided only at facilities desginated as an Ocular Gene Therapy Treatment Center.


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www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html

www.fda.gov/newsevents/newsroom/pressannouncements/ucm589467.htm

 

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About the Author

Sandy Macica, MS, RHIA, CCS
Sandy L. Macica is the former Director of Educational Content for Libman Education. Sandy is an experienced educator and coder with particular experience in developing online training for hospital coders in ICD-10-CM, ICD-10-PCS, and CPT® coding as well as coding certification exam preparation. Sandy is an enthusiastic presenter on all things coding and often speaks on complex coding topics for professional organizations and healthcare clients. Sandy is a long-time member of New York HIMA and was honored to receive the NYHIMA Distinguished Member Award in 2018.

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