Coding for High Risk Meds
(eg, Plaquenil)
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Coding for High Risk Meds
Office visit, 92 or 99
ICD examples:
362.55
371.11
695.4
710.0
714.0
Toxic maculopathy. Use E code of drug.
Anterior pigmentations
Lupus erythematosus
Systemic lupus erythematosus
Rheumatoid arthritis
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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
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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.
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Coding for High Risk Meds
2011 Plaquenil Screening Tests
(Am.Acad.Ophthal.)
Extended Ophthalmoscopy
Fundus Photography
Visual Field
Scanning Imaging, FAF, or mfERG
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Coding for High Risk Meds
Extended Ophthalmoscopy
-Should not be used as screening test alone, due
to low sensitivity. (AAO)
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Coding for High Risk Meds
Extended Ophthalmoscopy
-362.55 Toxic maculopathy, often paid. Use E
code for drug.
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Coding for High Risk Meds
Fundus Photography
-Not sensitive enough to identify early findings
associated with retinal toxicity. (AAO)
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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
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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)
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Coding for High Risk Meds
Visual Field – ICD
examples 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
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Coding for High Risk Meds
Scanning Imaging, FAF, or mfERG
Testing should include at least one of these
3. (AAO)
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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.
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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
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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.
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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.
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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
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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
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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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Evaluations
Questions
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