Reimbursement of optical coherence tomography (OCT) for diagnosis and therapy control in retinal diseases will be available from October 2019 via the EBM (Einheitlicher Bewertungsmaβstab, German Uniform Evaluation Standard).
The OCT imaging technique is based on different reflections of laser light through different tissue layers. The OCT is used in the ophthalmological field, especially for the examination of the retina and allows a representation of the various layers and parts of the retina - similar to histological sectional images. In retinal diseases, OCT should provide early diagnosis of pathological processes before they become noticeable, for example, by a deterioration in vision.
Patients with neovascular age-related macular degeneration or macular edema as a result of diabetic retinopathy are now eligible for the new statutory health insurance service. This was decided by the Federal Joint Committee (G-BA) at the end of 2018.
The National Association of Statutory Health Insurance Physicians (KBV) together with the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) have now set the reimbursement for optical coherence tomography (OCT) in the Evaluation Committee and added four new fee order items (GOP) to the EBM for billing.
The health insurance companies will pay €43.18 per eye extrabudgetary.
For the diagnostic of the right eye, ophthalmologists calculate the GOP 06336, on the left eye - the GOP 06337. Both services can be billed once in the treatment case and are rated with 399 points (€43.18).
OCT can also be used to control therapy in the indications listed above. Ophthalmologists, in this case, will calculate the GOP 06338 for the right and the GOP 06339 for the left eye diagnostic. These fee order items are also rated with 399 points (€43.18).
The two GOPs for therapy control can be calculated in addition to the supplementary services provided via GOP 06334 (for the right eye) and 06335 (for left eye) for intravitreal drug administration (IVM), which are already available in EBM. This is possible up to six times in case of disease.
However, the following restriction will apply: the new GOPs 06338 and 06339 cannot be calculated in the period of three weeks after the IVM. Ophthalmologists must state the date of the last IVM on their billing. In addition, the GOP 06338 and 06339 can be calculated only once in the period of 26 days.
The Evaluation Committee has decided to review the new services in two years. If necessary, this will lead to the correction of the current decision.
The full details in German can be found here.
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