• Savvy Coder

    How to Code for Glaucoma Procedures in the Anterior Chamber Angle

    By Cynthia Mattox, MD, Associate Professor of Ophthalmology, Tufts University School of Medicine, and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

    This article is from May 2018 and may contain outdated material.

    What does gonioscopy-assist­ed transluminal trabeculot­omy (GATT) using a suture or iTrack microcatheter (Ellex) have in common with procedures that use the Kahook Dual Blade (New World Medical), Trab360 (Sight Sciences), or Trabectome (NeoMedix)? Per the Acad­emy Health Policy Committee, these ab interno trabeculotomy (also known as goniotomy) techniques can be billed using CPT code 65820.

    CPT Code 65820: Goniotomy

    Code description. Trabecular mesh­work is incised and/or excised with a blade or other tool for at least several clock hours to create an opening of Schlemm’s canal into the anterior chamber. The approach is internal via a corneal incision into the anterior chamber.

    Rationale. These new tools and approaches enhance our ability to perform canal-based procedures by allowing better egress of aqueous out of the eye through the physiologic outflow system of collector channels, thereby lowering intraocular pressure (IOP).

    Coding clues. Keep in mind the following:

    • Goniotomy should not be coded in addition to other angle surgeries or canal implants.
    • Goniotomy treats congenital glauco­ma and adult open-angle glaucomas.
    • If using an ophthalmic endoscope, you can bill 66990 as well as 65820.
    • Payment is per eye.
    • For Medicare Part B patients, when surgery is performed bilaterally, sub­mit a 1-line item with modifier –50 (bilateral procedure) appended to the surgical code, per the Medically Unlikely Edits (MUEs) that became effective on April 1, 2013. Place a “1” in the unit field and double the charge.
    • This procedure does not qualify for coverage for team surgery, cosurgery, or an assistant-at-surgery.

    Reimbursement rates. The national averages are as follows:

    Surgeon allowable: $768.59
    Ambulatory surgery center (ASC) allowable: $1,772.23
    Hospital outpatient allowable: $3,610

    It is a major surgery. This means that it has a 90-day global period under Medicare Part B, though that might not be the case for commercial and Medicaid plans.

    7 Codes to Watch For

    While many CPT codes are bundled with the 65820 goniotomy code (see “CCI Bundling”), it is worth making a mental note of the 7 codes below, all of which can be unbundled when appropriate.

    65800 Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous

    65810 Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection

    65815 Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection

    66020 Injection, anterior chamber of eye (separate procedure); air or liquid

    66030 Injection, anterior chamber of eye (separate procedure); medication

    67250 Scleral reinforcement (separate procedure); without graft

    67500 Retrobulbar injection; medication (separate procedure, does not include supply of medication)

    CCI Bundling

    The Correct Coding Initiative (CCI) lists pairs of codes—known as bundled codes or CCI edits—that should not be billed separately when services are performed by the same physician on the same eye on the same day.

    Some pairs can be unbundled; others are mutually exclusive. Under certain circumstances, some of those CCI edits can be paid separately if you indicate to the payer (by appending a modifier code) that those circum­stances apply. This process is known as unbundling.

    Dozens of codes are bundled with 65820, but some can be unbundled. G0463, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13150, 13151, 13152, 13153, 65800, 65810, 65815, 66020, 66030, 67250, 67500, 92012, 92014, 92018, 92019, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99334, 99335, 99336, 99337, 99347, 99348, 99349, 99350, 99374, 99375, 99377, and 99378.

    Bundled with 65820, and can never be billed separately. 99149, 99150, 99155, 99156, 99157, 99446, 99447, 99448, 99449, 99495, and 99496.

    65820 is bundled with the following codes but can be unbundled.

    65850 Trabeculectomy ab externo
    65855 Trabeculoplasty by laser surgery
    66711 Ciliary body destruction; cyclo­photocoagulation, endoscopic

    Coding for ABiC and Visco360

    ABiC and Visco360 are used in ab interno procedures. They viscodilate Schlemm’s canal for at least several clock hours, without creating a goni­otomy.

    Use CPT code 66174 Transluminal dilation of aqueous outflow canal; with­out retention of device or stent.

    This should not be coded in addi­tion to any other angle procedure or canal implant.

    Case Scenario

    A 79-year-old patient with pseudoexfo­liation has mild glaucoma in the right eye and moderate glaucoma in the left. Two months earlier, he had undergone phacoemulsification, IOL implantation, and iStent implantation in the right eye.

    Today’s exam. In his right eye, his IOP is 28 mm Hg on maximum medi­cations, the iStent is mispositioned, and he has a large, atonic pupil with glare symptoms.

    Plan. Remove the iStent; perform ab interno trabeculectomy using the Tra­bectome; and perform pupilloplasty.

    Correct coding. The appropriate CPT and ICD-10 codes would be:

    • 65820–RT Trabectome and H40.1421 (payment is 100% of the allowable)
    • 65920–RT iStent removal and T85.898A (payment is 50% of the allowable)
    • 66680–RT Pupilloplasty and H21.561 (payment is 50% of the allowable)