Photrexa® Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) &

Photrexa ® (riboflavin 5'-phosphate ophthalmic solution)

Transitioning to New J Code: J2787

MA-01293A

DISCLAIMER

The information provided is for informational purposes only and

represents no statement, promise, or guarantee by Avedro concerning

levels of reimbursement, payment or charges. Codes are supplied for

informational purposes only and represent no statement, promise, or

guarantee by Avedro that these codes will be appropriate or that

reimbursement will be made. Information provided is not intended to

increase or maximize reimbursement by any payor.

MA-01293A

MA-01293A

• A J Code is part of the HCPCS Code Set and represents a medicinal substance for

billing and reporting purposes

• “J” codes include the majority of drugs and biologicals that should be reported with

infusions, injections, and supply codes that go hand in hand with CPT procedure based

coding used for billing and other reporting.

• HCPCS = Healthcare Common Procedure Coding System

• CPT = Current Procedural Terminology is a medical code set that is used to report

medical, surgical, and diagnostic procedures and services to entities such as

physicians, health insurance companies and accreditation organizations.

• J Codes are made up of one letter (J) and 4 numbers: JXXXX

• Unlisted codes provide the means of reporting and tracking services and procedures until a more specific

code is established.

• Miscellaneous/Unlisted J Codes must be billed with other identifying information (such as the NDC#) in

order to be affiliated with the proper drug or biologic

• Claims with Miscellaneous/Unlisted J Codes are processed manually at the payer due to the variety of

products with which it is associated

MA-01293A

• Unlike an unassigned or miscellaneous J Code, a dedicated J Code is permanent and typically not shared

with any other product or medicinal substance.

• The new dedicated J Code for Photrexa Viscous and Photrexa is:

J2787

Photrexa Viscous/ Photrexa Cross-Linking Kit

NDC:25357-025-03

MA-01293A

• Billing is based on date of the procedure regardless of the date product was purchased

• The NDC should still be reported as payers may still require an NDC to adjudicate the claim.

Product Administered 2018 Product Administered 2019

Bill using J3490 Bill using J2787

MA-01293A

Payers typically request the NDC entered in an 11-digit format, with an extra “0” added to the

beginning of the second section, without hyphens.

❖ 25357-025-03 would be 25357002503

❖ Payers may also require an N4- qualifier preceding the NDC.

!

• To ensure adequate reimbursement we recommend initially submitting claims with

o a copy of the purchase invoice,

o medical records, and

o the operative report to help with claims processing (for 0402T as well).

• Going forward the invoice should no longer be required.

MA-01293A

When billing for the Cross-

linking Kit NDC, 2 HCPCS

units may be billed in Box

24G.

Additional drug description

may be added to the shaded

portion of the line in Box 19

and 24, including the NDC, unit

of measure, and amount

administered.

CY 2019 Sample CMS 1500 Claim Form

N425357002201 Photrexa Viscous 1.46 mg/1 ml ML3

1234567890X

H18.62X

N425357002503 ML601 01 18 01 01 18 11 J2787 1 $XXXX.XX 2

01 01 18 01 01 18 11 0402T RT 1 $XXXX.XX 1

MA-00646E

Please Note: The information shown here is a general guideline only - actual payer and clearinghouse requirements may vary.

BOX 24B, SERVICE

Place of service code is 11 for physician office or 24 for freestanding ASC.

BOX 24D, SERVICE

CPT 0402T for corneal cross linking. HCPCS J2787 for Photrexa Viscous and Photrexa.

BOX 24E, SERVICE

Point to corresponding diagnosis code in Box 21.

BOX 24F, SERVICE

Billed charges associated with the procedure should reflect all necessary work, technical or practice expense or overhead. It is appropriate to bill separately for the drugs.

BOX 24A, SERVICE

Enter in date(s) of service.

BOX 24G, SERVICE

Bill 2 units with the Kit NDC to represent 6ML of drug because the HCPCS code description is “up to 3 ML”.

BOX 24, SERVICE – Shaded Portion of Line Item Include all details specific to drugs used for claims processing.

N4 – NDC identifier that precedes the actual NDC. Payer requirements for this vary.

National Drug Code (NDC) – Format this number to 11 digits by adding an extra “0” to the beginning of the 3-digit middle section. Payer requirements for this vary.

Unit of Measure – Photrexa Viscous and Photrexa are a physician administered drug, in drop form. The unit of measure is Milliliter or ML for a liquid, solution, or suspension.

“ML6” or Amount Used – The amount used with the Kit is 6 ML.

HCPCS code J2787 for Photrexa Viscous and Photrexa. (Riboflavin 51-phosphate,

ophthalmic solution, up to 3 ML) is effective January 1, 2019. Use this code for dates of

service on or after January 1, 2019.

National Drug Code (NDC)Most payers require this information for claims processing.➢ The NDC number for the Photrexa

Cross-linking Kit that contains the Photrexa Viscous and Photrexa in the

single use kit (separate foil pouches) is 25357-025-03.

➢ Payers typically request an 11-digit NDC . Add an extra “0” to the beginning of

the 3-digit middle section (25357002503).BOX 21. ICD-10-CM

Diagnosis code should be for keratoconusor corneal ectasia following refractive surgery.BOX 23. PA NUMBER

Enter prior authorization reference number.

Photrexa Cross-linking Kit, 25357002503, 6ML

• Process may vary by payer, we anticipate there may be variation in payers loading the

new J-code.

• For all payers ARCH will automatically request authorizations with J2787 beginning

January 1, 2019.

• ARCH will handle requests on a per case basis, based on payer guidance.

MA-01293A

• Payment may be affected by the provider’s contract, and the patient’s plan.

➢ Check contract language!

• Commercial payers establish their own reimbursement methodologies and

reimbursement can vary by payer.

• For example, a commercial payer may base payment on a percentage of Average

Wholesale Price (AWP).

MA-01293A

Example from Anthem:

AWP: $3,420 – 16% = $2,872.80

2 units= $2,872.80

1 unit = $1,436.40

1. When will the new J-code be loaded?

Most commercial payers will load the new J-code (J2787) within the first month after the effective date. Commercial payers will vary.

You may contact ARCH or your respective provider relations contact at your payers for specifics.

2. When will I be able to use the new J-code?

January 1, 2019 is the effective date. Most commercial payers will implement the effective date on January 1, or retroactively to

January 1, despite when they actually load the new code.

3. How will I know if my payers have loaded the new code?

You can contact your respective provider relations representative at your payers for specific information. ARCH and your Field

Reimbursement Manager (FRM) can help you as well.

4. How will the process for submitting claims be different?

For most payers you will no longer have to submit copies of invoices with your claims. Your claim form may need to be completed

differently regarding the how many units must be billed. (Please see previous slide for detail).

5. How much will I be reimbursed?

Reimbursement will vary from payer to payer but most use a price compendium that in most instances covers the cost of the drug plus

a small handling fee. You may contact your respective provider relations representative at your payers for specifics. ARCH and your

Field Reimbursement Manager (FRM) can help you as well.

MA-01293A

6. What if I bought my drug in 2018, can I still file with new J code?

The new J code should be used when the procedure is completed in 2019, regardless of the purchase date.

7. What if I treated in 2018, can I still file in 2019?

Yes. If you treated in 2018, you can file your claim for the 2018 procedure in 2019 using the old miscellaneous J Code

J3490.

8. What if I made a submission in 2018 with the miscellaneous J code and received low payment and want to

appeal. Should I still use the miscellaneous J code?

Always use the date of the procedure to determine which J code to use. If the date of the procedure was before

January 1, 2019, use the miscellaneous J code, J3490. If the procedure is completed on or after January 1, 2019,

use the new, dedicated J code, J2787

MA-01293A

ARCH Hotline (for questions about coding, billing,

claims submissions or payer coverage)

1-844-528-3311

Medical Information and Adverse Event Reporting(844) 528-3376 x 1

Avedro@Accelovance.com

Customer Service and Account Information(844) 528-3376 x 2

Info@Avedro.com

Technical Support and Field Service(844) 528-3376 x 3

Contact Info

Q & A

MA-01293A