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Issue Number - Name
0047 - Panretinal (Scatter) Laser Photocoagulation - Excess Frequency
Review Type
Automated
Claim Type
Outpatient Hospital (OPH) and Physician/ Non-physician Practitioner
Region and State
J6, JK, J15
Date Approved
2017-02-23

Description

Potential incorrect billing occurs when Panretinal (Scatter) Laser Photocoagulation (CPT code 67228) is paid more than once per eye, within the global surgery period (90 days for DOS prior to 1/1/2016 and 10 days for DOS 1/1/2016 and after).

Affected Code(s)

  • CPT 67228

Applicable Policy References

  • Title XVIII of the Social Security Act (SSA), 1833(e)
  • Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A)
  • CMS Pub.100-08, Program Integrity Manual, Chapter 3, 3.5.1 and 3.6 
  • CGS Administrators (CGS) Local Coverage Determination (LCD), L31888 (Retired 09/30/2015)
  • CGS LCD, L34064 
  • National Government Services (NGS) LCD L28497 (Retired 09/30/2015)
  • NGS LCD, L33628 (Revised 10/01/2016)