G461 – Bilateral PDT
OHIP Diagnostic & Therapeutic Procedures Code — DIAGNOSTIC AND THERAPEUTIC PROCEDURES · Schedule of Benefits
Ocular photodynamic therapy (PDT) is, subject to the limitations set out below, an insured service when rendered by an ophthalmologist. PDT must include completion and submission of patient registration and drug requisition forms, establishment of intravenous access, supervision of drug infusion and personal application of non-thermal diode laser for activation of verteporfin. PDT is insured only if the patient's clinical condition meets all of the following: a. the patient has predominantly classic subfoveal choroidal neovascularization (CNV) secondary to either age-related macular degeneration (AMD), Presumed Ocular Histoplasmosis Syndrome or pathologic myopia. Predominantly means that the area of classic subfoveal CNV is equal to or greater than 50% of the total CNV lesion, as determined by fluorescein angiography and documented by retinal photographs retained on the patient's permanent medical record; b. treatment is commenced within 30 months after initial diagnosis of predominantly classic subfoveal CNV secondary to AMD, Presumed Ocular Histoplasmosis Syndrome or pathologic myopia; c. the patient's visual acuity is equal to or worse than 20/40; and d. for each repeat therapy, recurrent or persistent CNV leakage is detected by fluorescein angiography and documented by retinal photographs retained on the patient's permanent medical record.
When to Use
- Use G461 when performing bilateral ocular photodynamic therapy for patients with predominantly classic subfoveal CNV secondary to AMD, Presumed Ocular Histoplasmosis Syndrome, or pathologic myopia.
- Use this code specifically when the classic CNV component occupies 50% or more of the total lesion area as confirmed by fluorescein angiography.
Common Pitfalls
- Billing G379 for intravenous access on the same day as G461 will result in a zero-dollar payment, as it is considered bundled into the PDT procedure.
- Failure to retain pre-procedure retinal photographs in the patient's permanent record constitutes a non-compliance risk that will lead to claim rejection or recovery upon audit.
- Billing G461 for conditions outside the specified diagnoses (AMD, Histoplasmosis, or pathologic myopia) is strictly prohibited and will be deemed an uninsured service.
Billing Tips
- Always bill your assessment and angiography codes in addition to G461, as these are explicitly permitted, but ensure you do not bill retinal photography as a separate line item.
- Maintain a strict 3-month interval between treatments per eye to align with clinical guidelines and avoid potential audit scrutiny regarding medical necessity.
Effective: April 1, 2025
J. Diagnostic and Therapeutic Procedures
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
Procedure
Diagnostic and Therapeutic Procedures
Retinal photographs must be made prior to the procedure and retained on the patient's permanent medical record.
1. G379 rendered to same patient in conjunction with G460 or G461 is an insured service payable at nil.
2. G460 rendered to same patient same day as G461 is an insured service payable at nil.
3. Assessments and angiography are payable in addition to PDT. Retinal photography is insured as a specific element of the assessment and is not payable separately.
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