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  • MIGS Reimbursement

    By Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
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    Update: On Aug. 29, 2018—after the article below was published—Alcon announced a voluntary, global recall of the CyPass microstent.

    You report most surgical procedures, testing services, and exams using Category I Current Procedural Terminology (CPT) codes, which are 5-character numeric codes. However, MIGS don’t have Category I codes. Instead, you use Category III codes, which are 5-character alphanumeric codes that end with T.  Category III codes are temporary codes for new technologies, services, and procedures that don't yet meet the criteria for receiving a Category I code.

    4 Category III CPT Codes for MIGS

    0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork; initial insertion

    • iStent
    • In conjunction with cataract surgery
    • Medicare benefit
    • Coverage varies by commercial payer
    • Carrier priced

    0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space

    • iStent Supra Micro-Bypass Stent
    • Approved with or without cataract surgery
    • Coverage is payer specific

    0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device

    • XEN Gel Stent
    • Approved with or without cataract surgery
    • Coverage is payer specific 

    + 0450T Each additional device

    • Not separately billable to Medicare or Medicare beneficiaries
    • If commercial plan doesn’t cover 0449T, patient is responsible for all additional devices inserted

    0474T Insertion of anterior segment drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space

    • CyPass
    • Approved only in conjunction with cataract surgery
    • Coverage is payer specific 

    Reimbursement for MIGS Procedures

    What does Medicare Part B cover? Medicare Part B assigns payment to facilities for the MIGS Category III codes to cover the cost of the device. However, payment to the physician is not assigned because the codes have not been valued by the Relative Value Scale Update Committee (RUC). Until the Medicare Administrative Contractor (MAC) that is responsible for Medicare payments in your state starts assigning payment to physicians for MIGS procedures, your patients may be responsible for payment (see “Give patients advance notice of uncovered services,” below).

    Check your MAC’s local coverage determinations (LCDs). When a MAC starts reimbursing physicians for the Category III MIGS procedures, it is likely to publish an LCD or an article. Visit your MAC’s LCD database to see if your MAC has published an LCD or an article for MIGS procedures.

    Noridian said it would start covering 0474T (CyPass) beginning Jan. 1, 2018. An allowable is not published. It is priced by the contractor. Noridian is the MAC for Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming. It also is the MAC for American Samoa, Guam, and Northern Mariana Islands.

    Palmetto reimburses for minimally invasive glaucoma stents. In December, Palmetto published its fees for 2018. Palmetto is the MAC for North Carolina, South Carolina, Virginia, and West Virginia.

    What about commercial plans? Commercial insurance plans might not cover the facility or the surgeon, in which case the patient would be responsible for payment—even with preauthorization. When preauthorizing, ask for an allowable. That will give you an indication that the code is covered.

    Give patients advance notice of uncovered procedures. If you are not sure of Medicare’s coverage for a procedure, you should ask the Part B patient to sign an Advance Beneficiary Notice (ABN) of Noncoverage ahead of time. By signing the ABN, the patient accepts responsibility for mak­ing payment if Medicare denies reimbursement; without an ABN, you can’t bill the patient. Note: The ABN is for Medi­care Part B patients only; commercial payers may have their own form or may require prior authorization to determine coverage. Be sure to append modifier –GA to the Category III code. This modifier notifies Medicare that you have an ABN on file.