Ophthalmology and Optometry Coding Alert

Learn how to differentiate between goniopuncture and goniotomy.

Primary open-angle glaucoma (POAG) affects millions of Americans, many of whom can be treated with minimally invasive glaucoma surgery (MIGS) procedures. Thanks to innovative new products, such as the Streamline viscoelastic injector and iAccess trabecular trephine, ophthalmic surgeons have new weapons they can add to their arsenal against POAG.

As often happens with the rollout of new technology, missteps in coding have gained payer attention. To help you keep your eye care practice from being inundated with claim denials, here’s a breakdown of what you need to know about goniotomy, MIGS, and how to avoid inappropriate billing of these novel glaucoma procedures.

Get to Know Goniotomy

Goniotomy is minimally invasive surgery to relieve eye pressure in patients with glaucoma. It involves the ophthalmologist creating an opening in the first layer of the eye’s natural drainage system, the trabecular meshwork, using a blade or other surgical instrument to allow for drainage of aqueous humor. Once the physician enters the anterior chamber using a gonioknife, they incise and/or excise the trabecular meshwork, located where the iris meets the sclera, to create an opening into Schlemm’s canal from the anterior chamber.

The July 2018 CPT^® Assistant provides the following description of goniotomy, “After gonioscopy under the microscope with traction sutures in place and with a special gonioprism, the gonioknife is used to enter the cornea, pass across the iris, and slit Barkan’s membrane for the desired area, usually 180 degrees.”

Understand Coding and Billing Nuances

You should use CPT^® 65820 (Goniotomy) when your ophthalmic surgeon performs trabeculotomy ab interno, but only when the trabecular meshwork is opened for at least three contiguous clock hours, clarifies the American Academy of Ophthalmology (AAO) in a fact sheet. Payment is per eye.

When the surgery is performed bilaterally on a Medicare patient, the fact sheet instructs you to submit one line item with the surgical code and modifier 50 (Bilateral procedure) appended. Then, put a “1” in the unit field and double the charge.

The AAO’s fact sheet also provides specific guidance related to Streamline and iAccess: “Since there is no specific CPT^® code for goniopuncture or so-called microgoniotomy procedures … If the procedure performed consists of several punctures, injection of a small amount of viscoelastic, or other limited interventions, report using unlisted CPT^® code 66999 [Unlisted procedure, anterior segment of eye].”

To highlight the distinction between several punctures or injections and traditional incisional goniotomy, the fact sheet specifies, “When multiple incisions are performed opening the trabecular meshwork over an area of at least 90 degrees, report using CPT^® code 65820.”

Review These FAQs Before Reporting Multiple Procedures

When a provider performs glaucoma intervention together with another procedure, such as cataract removal and stent placement, make sure to double-check the reporting rules before submitting the claim. “Goniotomy should not be coded in addition to other angle surgeries or canal implants,” according to Cynthia Mattox, MD, past president of the American Glaucoma Society (AGS), and Sue Vicchrilli, COT, OCS, past academy director of coding and reimbursement.

“Echoing that guidance, Novitas and First Coast Service Options, Medicare Administrative Contractors [MACs], published in their Local Coverage Determination [LCD] L38223 that, ‘Goniotomy procedure performed in conjunction with the insertion of a glaucoma drainage device is considered not medically reasonable and necessary,’” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

While the National Correct Coding Initiative (NCCI) edits do not currently contain a bundle for 65820 and 66989 (Extracapsular cataract removal with insertion of intraocular lens prosthesis … complex … with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device …) or 66991 (Extracapsular cataract removal with insertion of intraocular lens prosthesis …), the Novitas and FCSO LCD and the AAO/AGS guidance are instructive and should not be ignored, Johnson adds.

When it comes to cataract surgery with endoscopic cyclophotocoagulation (ECP) (CPT^® codes 66987 and 66988), effective Oct. 1, 2022, the NCCI edits retain the bundle of codes 65820 and 66987 (Extracapsular cataract removal with insertion of intraocular lens prosthesis … complex … with endoscopic cyclophotocoagulation) but no longer bundle goniotomy with 66988 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique ... with endoscopic cyclophotocoagulation), Johnson points out.

Note Changes to Noridian’s Goniotomy LCD

On Oct. 1, 2022, Noridian — MAC for Jurisdictions E and F — changed its goniotomy coverage policy to the following:

• Since there is no specific CPT^® code for goniopuncture or so-called microgoniotomy procedures, the unlisted CPT^® code 66999 … should be reported in these instances.
• Any procedures performed which consists of single or multiple small punctures and/or injections of small amounts of viscoelastic, or other limited interventions should be reported using unlisted CPT^® code 66999. Specifically, goniotomy (CPT^® code 65820) should not be coded in addition to other angle surgeries, stent insertions, or Schlemm canal implants or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure.
• In order to report a goniotomy, an extensive incision of the trabecular meshwork around the eye, at the least and generally more than 3 clock hours, must have been performed. Documentation regarding the reasonable and necessary premise for the work must be present.