MedicaidCoverageMedium impact
Newsletter Vol. 14, No. 07
New Jersey Medicaid·NJ · Ophthalmology·Medical Policy
Effective date
Feb 1, 2004
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid now covers verteporfin (Visudyne) and ocular photodynamic therapy (O.P.T.) for treatment of age-related macular degeneration, effective February 1, 2004. Coverage is limited to ophthalmologists who are retinal specialists treating patients meeting specific clinical criteria (visual acuity ≥20/200, classic CNV ≥50% of lesion, qualifying ICD-9 diagnosis). Billing requires specific HCPCS and CPT codes with modifier requirements and defined fee allowances.
Action Required
By February 1, 2004: (1) Billing team must configure billing system to accept claims for verteporfin therapy only from ophthalmologists who are retinal specialists. (2) Update billing software to enforce patient eligibility criteria: best corrected visual acuity ≥20/200, classic CNV occupying ≥50% of lesion, and ICD-9 diagnosis codes 11502, 11592, 36221, or 36252. (3) Configure claim submission to use HCPCS code J3395 with maximum fee allowance of $1,687.50 per 15mg vial (based on AWP as of May 15, 2003). (4) Set up CPT codes 67221 (primary eye, $283 specialist/$241 non-specialist) and 67225 (second eye, $23 specialist/$20 non-specialist) with mandatory modifiers LT or RT on all claims for both initial and subsequent treatments. (5) Ensure modifier 50 (bilateral) is NOT used with these codes; use distinct codes 67221 and 67225 instead. (6) Train providers and billing staff that E&M services, fluorescent angiography, and other ocular diagnostics may be billed separately when medically necessary on same date of service. (7) Retain policy documentation in filing system. Claims submitted without meeting all criteria or using incorrect modifiers will be denied. Contact DMAHS Vision Care Consultant at (609) 588-2777 with questions.