Clinical Scorecard: Coding and Billing Updates for Geographic Atrophy Drugs

At a Glance

Key Highlights

• New GA drugs require updated coding and billing practices.
• Pegcetacoplan transitioned to HCPCS code J2781 as of October 1, 2023.
• Avacincaptad pegol will use HCPCS code J2782 effective April 1, 2024.
• JW and JZ modifiers are required for accurate billing of discarded drug amounts.
• Patient assistance programs are available for those in need.

Guideline-Based Recommendations

Diagnosis

• Use specific ICD-10 code for nonexudative AMD (e.g., H35.31x1 for the right eye).

Management

• Stay informed about individual payor guidelines to prevent claim denials.

Monitoring & Follow-up

• Regularly review updates from authoritative sources like the American Academy of Ophthalmology.

Risks

• Patients may face delayed or skipped treatments due to funding issues.

Patient & Prescribing Data

Patients requiring treatment for geographic atrophy.

Vials of drugs may be issued at no cost through patient assistance programs.

Clinical Best Practices

• Ensure accurate documentation of medication name, dosage, and administration route.
• Calculate billing units based on drug dosage and volume accurately.

References

• American Academy of Ophthalmology
• Centers for Medicare & Medicaid Services (CMS)