• Savvy Coder

    MIGS Update—How to Code for Combined Glaucoma Procedures

    By David B. Glasser, MD, Academy Secretary for Federal Affairs, Michael X. Repka, MD, MBA, Academy Medical Director for Governmental Affairs, and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Is your practice up to speed on the new codes for minimally invasive glaucoma surgery (MIGS)?

    What Changed on Jan. 1?

    0191T and 0376T deleted. On Jan. 1, 2022, CMS deleted Category III code 0191T Insertion of anterior segment aqueous drainage device, without ex­traocular reservoir; internal approach, into the trabecular meshwork; initial insertion. The agency also deleted the add-on code +0376T for extra stents.

    New codes. 0191T was replaced by two Category I codes (66989 and 66991) and a Category III code (0671T):

    66989 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemul­sification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., 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 (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.

    66991 Extracapsular cataract re­moval with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.

    0671T Insertion of anterior seg­ment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more.

    Hydrus, iStent, or iStent Inject

    If you combine cataract surgery with insertion of a Hydrus (Ivantis), iStent (Glaukos), or iStent Inject, submit 66991 if the cataract surgery is tradi­tional and 66989 if it is complex.

    Preauthorization tip. As the need for complex cataract surgery isn’t always known preoperatively, seek preauthori­zation for 66989 as well as for 66991.

    Allowables. It is wise to check each payer’s allowable for a new code.

    Xen Gel Stent

    Coding for the Xen Gel Stent (Allergan) is the same as in 2021.

    With cataract. When inserting the Xen stent in conjunction with a cataract procedure, submit Category III code 0449T plus either 66984 (traditional cataract surgery) or 66982 (complex).

    Stand-alone procedure. When Xen insertion is a stand-alone procedure:

    • If ab interno, submit 0449T, along with +0450T for each additional device.
    • If ab externo, submit 66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach.

    Canaloplasty and MIGS

    Canaloplasty. When a 360-degree viscodilation is performed, submit 66174 Transluminal dilation of aque­ous outflow canal; without retention of device or stent, canaloplasty. (Note: If you inject viscoelastic into a limited portion of the canal via an opening cre­ated through the trabecular meshwork, don’t use 66174. Use 66999 Unlisted procedure, anterior segment of eye.)

    With Hydrus or iStent. What if you combine canaloplasty with insertion of a Hydrus or iStent device?

    • If there was no concurrent cataract surgery, submit 66174 plus 0671T.
    • If combined with cataract sur­gery, submit 66174 plus either 66989 (complex cataract surgery) or 66991 (traditional cataract surgery).

    With Xen. If you combine canaloplas­ty with insertion of the Xen device, submit 66174 and 0449T, along with +0450T for each additional device. If you also combined cataract surgery, submit those codes plus 66984 or 66982 for traditional or complex cataract surgery, respectively.

    Cataract, ECP, and MIGS

    What if you perform cataract surgery with concomitant endocyclophoto­coagulation (ECP) plus insertion of a MIGS device? You have some options.

    Option 1. You could submit CPT 66999 Unlisted procedure, anterior segment of eye. (Note: The MIGS and ECP procedures are not stand-alone in this case, which means that it would be inappropriate to submit 0671T or 66711 in combination with one of the cataract codes.)

    Option 2. For the cataract and MIGS components of the procedure, submit 66989 (if cataract surgery is complex) or 66991 (if traditional) and append modifier –22 Increased procedural ser­vices for the ECP component.

    Option 3. For the cataract and ECP, submit 66987 (if the cataract surgery is complex) or 66988 (if traditional), and append modifier –22 Increased procedural services for the stent.

    What’s a Category III Code?

    Category III codes help the CPT Edi­torial Panel collect data on emerging technologies, services, and procedures. These data are then used to determine whether new Category I codes are needed. A Category III code uses a 5-character alphanumeric code ending with T, such as 0671T. Insurers can choose whether or not to reimburse Category III codes; if they don’t, the patient is typically responsible for payment.