Ophthalmology and Optometry Coding Alert

Pay close attention to op note details to ensure your reporting is complete.

Glaucoma is a chronic progressive condition in which persistently raised intraocular pressure (IOP) damages the optic nerve and results in irreversible vision loss. While standard glaucoma surgeries are often effective at lowering eye pressure and preventing disease progression, they have a long list of potential complications.

An excellent alternative to traditional angle surgery in lowering IOP is minimally invasive glaucoma surgery (MIGS) procedures, which provide safer options with higher success rates and reduced recovery time. As the use of MIGS grows, so does the coding and coverage for these surgical cases.

If you think you could benefit from some straight talk about how coding for MIGS has changed to ensure you’re up on the latest in glaucoma surgery reporting, keep reading.

Examine the Code Evolution

“Recognizing the widespread adoption of 0191T (Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork …) during the prior 10 years, the Centers for Medicare & Medicaid Services (CMS) advised AMA’s CPT^® Editorial Panel in 2019 that the temporary, new technology, Category III CPT^® code created in 2009 was no longer appropriate and that a permanent, Category I CPT^® code was needed,” according to Kevin J. Corcoran, COE, CPC, CPMA, FNAO, president and co-owner of Corcoran Consulting Group in Springfield, Missouri.

This set the wheels in motion, and on Jan. 1, 2022, CMS deleted 0191T and add-on code +0376T (… each additional device insertion …) for extra stents and added two Category I codes to report stent procedures involving cataract surgery and an aqueous drainage device (ADD): 66989 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more) and 66991 (Extracapsular cataract removal with insertion of intraocular lens prosthesis … manual or mechanical technique … with insertion of intraocular ... anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more). The AMA also added a new temporary Category III code, 0671T (Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more), to report a stand-alone stent insertion procedure.

Remember: Payers can choose whether or not to reimburse Category III codes; if they don’t, the patient is typically responsible for payment, presuming they have been advised in advance and signed an Advance Beneficiary Notice (ABN) or appropriate waiver.

Peruse These Coding Pearls for Stent Implants

“Pay close attention to FDA package labeling and indications for use when considering stent implants. Hydrus (Ivantis) and iStent inject (Glaukos) are indicated for use with concurrent cataract surgery. Category III code 0671T represents the use of iStent Infinite not performed with a concurrent cataract procedure. Payment for code 0671T, describing a stand-alone procedure, is made at each payer’s discretion; there is no published allowed amount,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Why? “As a Category III code for new technology, the procedure has not been valued by the Relative Update Committee,” notes the American Academy of Ophthalmology (AAO) stent coding fact sheet (www.aao.org/Assets/edd35b50- 5596-49b2-8709-22316ead6c41/637975734180730000/istent-istent-inject-hydrus-fs-pdf?inline=1).

“When preauthorizing, ask for an allowable. For the Medicare Part B patient, obtain an ABN and append modifier GA [Waiver of liability statement issued as required by payer policy, individual case] to 0671T,” per the fact sheet.

When the surgeon combines cataract surgery with stent insertion, submit either 66991 (if the cataract surgery is traditional) or 66989 (if it is complex). To support your claim, be sure to link both glaucoma and cataract ICD-10-CM codes.

“Review policies and ‘Indications for Use’ carefully,” Johnson advises. “Mild to moderate glaucoma is required, not severe stage or glaucoma suspect. Payers vary on requirements for refractory glaucoma, history of prior glaucoma medications, and history of failed glaucoma surgery.”