Advocacy & Practice Updates — Advocacy & Practice
ASRS Seeks to Remove CMS Edit for Billing Wet and Dry AMD Treatments in the Same Month
According to ASRS members across the nation, a CMS claims system edit is causing a significant number of traditional Medicare and Medicare Advantage claim denials for treating wet age-related macular degeneration (wet AMD) with an anti-VEGF product, and geographic atrophy (GA) secondary to AMD treated with complement inhibitors when treatment for each disease is administered within 25-28 days. The first treatment is usually reimbursed, but the second drug and the injection code (CPT Code 67028) are being denied.
As ASRS and AAO work to meet with CMS to request that this edit be removed, retina practices should appeal the claims. The basis for the appeal is that GA and wet AMD are different diseases (uniquely separate forms of advanced AMD) and are treated with different classes of drugs, all FDA labels are being followed. If you need assistance, please contact the ASRS Director of Practice Management, monica.horton@asrs.org.
(Published 2.18.25)