Only five years ago, a small company in southern Florida, Bio-Tissue, pursued getting a CPT code for the placement of an amniotic membrane on the eye. In 2011, Bio-Tissue achieved its goal and the American Medical Association created CPT code 65778 (currently defined as: “Placement of amniotic membrane on the ocular surface; without sutures,”) in recognition of the importance of delivering the wound healing properties of cryopreserved amniotic membrane to the ocular surface without the use of sutures. 

The use of amniotic membranes on the ocular surface is now a well-established therapy that can speed healing, particularly for severe inflammatory conditions. It may become even more important as we move to an outcomes-based payment system, considering it could provide significant cost savings. However, not all amniotic membranes are created equal, which CMS noted in a recent Local Coverage Determination:¹

“Amnion [Bio-Tissue] can be prepared for implantation a number of ways. Heat- or air-dried amniotic membrane loses some of its biologic properties and is not ideal for ocular surface rehabilitation. The tissue can be lyophilized (freeze-dried), which induces minimal change in its properties. Amnion can be preserved in cold glycerol and cryopreserved and stored frozen at -80 degrees. The cryopreservation method allows for greater retention of the membrane’s structural, physiological and biochemical properties responsible for its dramatic healing and easier handling intraoperatively.” 

So while it may be tempting to use less effective technology to increase profitability, it may not be the wisest choice in the era of outcomes-based care.

Surgical Coding

Clinical application of an amniotic membrane is virtually identical to the insertion of a bandage contact lens; however, CPT references it as a surgical procedure, and clinicians must remember to follow surgical coding rules. 

Coding for a minor surgical procedure is not difficult. In accordance with minor surgical rules, an office visit (either 920XX or 992XX) is generally not separately billable when performed on the same date of service as CPT code 65778. Reimbursement for the 65778 code already includes compensation for the office visit related to the decision to perform this procedure. It would be rare to append modifier -25 to an E/M office visit performed on the same day as the application of an amniotic membrane.

As of January 1, 2016, the global period was reduced from 10 days to zero, meaning there is no longer a period of time following the application of an amniotic membrane incorporated into the payment. Each follow up after the application, other than on the day of the procedure, is now billable. This does not mean you can bill simply for the removal of the membrane. You have to meet the requirements and definitions for an office visit just as you would for any follow-up visit, whether it be a 9921X or 9201X.

For CMS, a separate charge and reimbursement for the supply of the amniotic membrane is not allowed, as it’s bundled into the reimbursement for the procedure itself, so clinicians cannot bill for V2790 with 65778. Rarely, commercial carriers may have policies that allow for reimbursement of the procedure and the materials, and if so, the appropriate HCPCS Level II code is V2790 (“Amniotic membrane for surgical reconstruction, per procedure”). My advice—don’t bill for it as a separate item.

OSD Particulars

With respect to ocular surface disease (OSD), amniotic membranes are generally reserved for more advanced disease, as you are not treating the “dry eye,” but the corneal sequelae of the OSD, so medical necessity for this procedure would generally be established after the failure of other management strategies. 

Success in the Future

The growing popularity of amniotic membranes reminds us how far we have come in being able to provide emerging technology in caring for our patients—providing outcomes we could only dream of a few years ago. Your long-term success will always depend on your ability to properly establish medical necessity, having a meticulous medical record and following the detailed documentation rules the ICD-10 requires. 

How Membranes Work Read this month’s feature "The Ins and Outs of Corneal Wound Healing” by Tarah Lee, OD, to learn about the clinical performance of amniotic membranes.

1. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Amniotic Membrane- Sutureless Placement on the Ocular Surface (L36237). www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=369&ContrVer=1&CntrctrSelected=369*1&s=All&DocType=Active%7CFuture&bc. Accessed March 8, 2016.