Optometrists are on the front lines for diagnosing age-related macular degeneration (AMD). Geographic atrophy (GA) is an advanced form of AMD that leads to progressive vision loss.¹ Recent advancements in treatment include new drugs, necessitating updates and careful attention to coding and billing practices in the offices of optometrists and ophthalmologists.²

Coding for New GA Medications

Initially, newly approved GA drugs are reported using Not Otherwise Classified (NOC) Healthcare Common Procedure Coding System (HCPCS) codes.³ For example, pegcetacoplan (Syfovre) was initially billed under HCPCS code J3490.⁴ However, as of October 1, 2023, it transitioned to the permanent HCPCS code J2781, which should be used for billing.⁵​ Similarly, avacincaptad pegol (Izervay) received its permanent HCPCS code, J2782, effective April 1, 2024.¹

Billing Units and Administration

Billing units are calculated based on the drug's dosage and volume.⁴ For instance, pegcetacoplan is administered at 15 mg (0.1 mL), equating 15 billing units.⁶ A single 2-mg vial of avacincaptad pegol is equivalent to 20 billing units. It's crucial to report the exact volume administered to ensure accurate billing and reimbursement.

Modifiers for Drug Administration

Effective July 1, 2023, the Centers for Medicare & Medicaid Services (CMS) require the use of the JW modifier to indicate discarded drug amounts and the JZ modifier when no drug is wasted. This change aims to enhance billing accuracy for single-dose drug containers.⁷

Frequency Limitations and Payor Policies

Be aware of frequency limitations, such as the "28-day rule," which restricts the administration of certain intravitreal injections within 28 days.² This can be tricky when a patient presents with the need for both anti–vascular endothelial growth factor (anti-VEGF) and GA treatments. While GA treatments may not be subject to this rule, payor policies may still impose such restrictions. It's essential to stay informed about individual payor guidelines to prevent claim denials.³

Documentation and Compliance

Accurate and thorough documentation is vital. Ensure that all claims include the medication's name, dosage, administration route, and the specific ICD-10 code for nonexudative AMD (eg, H35.31x1 for the right eye). Detailed records support the medical necessity of treatments and facilitate smoother reimbursement processes.⁷

Good Days’ Funding Runs Out

Good Days (also known as the Chronic Disease Foundation), a nonprofit that helps cover treatment costs for patients with chronic and life-altering diseases, has run out of funding for 2025. This affects patients relying on their financial assistance for intravitreal injections such as those that treat GA. Without this support, many patients face sudden unaffordable out-of-pocket costs. This puts them at risk for delayed or skipped treatments, which could lead to irreversible vision loss. Health care providers may also experience increased administrative burdens as they scramble to either find alternative funding sources or manage treatment disruptions for affected patients.⁸ Fortunately, there are patient assistance programs such as those provided by the drug companies Apellis and Astellas. When available, vials of drugs are issued at no cost to those in need.

Staying Updated

Coding and billing practices are subject to change. Regularly review updates from authoritative sources such as the American Academy of Ophthalmology and monitor CMS announcements to ensure compliance and optimize reimbursement.​ By understanding and implementing these coding and billing practices, health care providers can effectively manage the complexities associated with GA treatments and ensure patients receive timely and appropriate care.​³

References

1. Daily Medical News. Geographic atrophy treatment receives permanent J-code. March 28, 2024. https://www.healio.com/news/ophthalmology/20240328/geographic-atrophy-treatment-izervay-receives-permanent-jcode
2. American Academy of Ophthalmology. Geographic atrophy–how to get paid for new treatments. EyeNet Magazine. November 1, 2023. https://www.aao.org/eyenet/article/geographic-atrophy-how-to-get-paid-new-treatment
3. Woodke J. Prepare your practice for GA reimbursement. Retina Today. November/December 2023. https://retinatoday.com/articles/2023-nov-dec-supplement2/prepare-your-practice-for-ga-reimbursement
4. NC Medicaid Division of Health Benefits. Pegcetacoplan injection, for intravitreal use (Syfovre™) HCPCS code J3490 - Unclassified drugs: Billing guidelines. May 24, 2023. https://medicaid.ncdhhs.gov/blog/2023/05/24/pegcetacoplan-injection-intravitreal-use-syfovretm-hcpcs-code-j3490-unclassified-drugs-billing
5. Woodke J. New year, new codes: Time to revisit your practice’s internal resources. EyeNet Magazine. January 1, 2024. https://www.aao.org/eyenet/article/new-year-new-codes
6. Woodke J. Think outside the box: Coding for the new retina drugs. Retina Today. July/August 2024. https://retinatoday.com/articles/2024-july-aug/think-outside-the-box-coding-for-new-retina-drugs
7. Corcoran SL. Coding & Reimbursement: The answer for discarded drugs. Ophthalmology Management. 2023;27(September 2023):16, 51. https://www.ophthalmologymanagement.com/issues/2023/september/coding-and-reimbursement
8. American Society of Retina Specialists. ASRS provides resources for patients to consider options following Good Days insolvency. February 25, 2025. https://www.asrs.org/advocacy/updates/10408/asrs-provides-resources-for-patients-to -consider-options-following-good-days-insolvency

Mary Beth Yackey, OD practices at the Cincinnati Eye Institute in Ohio and Kentucky, where she is a member of the vitreoretinal team. She is a paid speaker for Apellis and Astellas and a consultant for OcuTerra, Optos, Notal Vision, Novartis, Reliance Ophthalmic, and Topcon.

This editorial content was supported via unrestricted sponsorship.