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Reimbursement

The following reimbursement information is intended to provide health care professionals with information related to billing, coding, and reimbursement requirements that may apply to EyeIC products. It is being provided for general informational and educational purposes only, and is not intended, and does not constitute, reimbursement or legal advice. Use of codes identified here does not guarantee coverage or payment at any specific level and is not intended to increase or maximize payment by any payer. Laws, regulations and coverage policies are complex and updated frequently. In addition, reimbursement policies vary widely from insurer to insurer and will reflect different patient conditions. You should check the current law and regulations and insurer's policies to confirm the most current coverage, coding or billing requirements. Any questions should be directed to your attorneys or reimbursement specialist. The health care professional is responsible for all aspects of reimbursement, including using codes that accurately reflect the patient's condition, procedures performed, and products used and ensuring the veracity of all claims submitted to third party payers.

Approved Indication Under US FDA 510(k) Pre-Market Clearance

MatchedFlicker is indicated for use by health care professionals to collect, store, and spatially calibrate (i.e., register and align) images of the posterior segment of the human eye.

Coding Highlights

CPT Codes

Category III CPT codes are temporary codes that describe emerging technologies or services. Physicians and facilities need to establish a charge amount to be submitted with a Category III CPT code. Category III CPT codes are eligible for coverage and reimbursement by payers. When Category III CPT codes are submitted on claims, they may be subject to manual review by payers to make a determination on medical necessity and therefore payment. Coverage and reimbursement is not guaranteed, and the use of such codes may require additional documentation to be submitted to payers in order to justify the medical necessity of the procedure performed. The table below identifies the possible CPT code(s) that may be used to describe the MatchedFlicker procedure. Category III CPT code 0380T became effective for use January 1, 2015 and describes the digital analysis of change over time from an animation of retinal images. Physicians and facilities are responsible for accurately selecting CPT procedure codes to describe the procedures performed.

CPT Code Descripton
0380T Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report

Payment Highlights

Medicare Payment

Because Category III CPT codes typically reflect new and emerging technologies, CMS does not establish national payment rates on the Medicare Physician Fee Schedule for these types of procedures.

Payment for Category III CPT codes will be determined by individual Medicare contractors on a case-by-case basis. Physicians need to establish a charge amount to be submitted with these types of codes. Claims for professional services submitted under Category III CPT codes are often manually reviewed by payers.

The payment methodology for a procedure submitted under a Category III CPT code varies. In some instances, Medicare will calculate payment based on the amount charged on the claim. In other cases, payment will be determined by comparing work involved with MatchedFlicker to other similar procedures.

Private Payer Payment - Physician

Payment for Category III CPT codes will be determined by private payers on a case-by-case basis. Physicians need to establish a charge amount to be submitted with these types of codes. Claims for professional services submitted under Category III CPT codes are often manually reviewed by payers. Additionally, because Category III CPT codes are often used to identify emerging technology, insurers unfamiliar with MatchedFlicker may request additional materials to support coverage when submitting claims.

The payment methodology for a procedure submitted under a Category III CPT code varies. In some instances, private payers will calculate payment based on the amount charged on the claim. In other cases, payment will be determined by comparing work involved with MatchedFlicker to other similar procedures.

Payment rates for specific CPT codes may be obtained from the payer’s published physician fee schedule or by contacting the payer directly.

For more information, please click here to contact EyeIC.