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  • How to Code MIGS Correctly

    Micro-invasive glaucoma surgeries (MIGS) are becoming much more common, and payers are beginning to allow for coverage. However, there are multiple codes to select from, and payers do not reimburse for all of them. Here’s how you can ensure you are using the most appropriate code for specific MIGS procedures.

    Category III Code Facts

    Billing for implanted MIGS falls under Category III codes:

    • 0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork; initial insertion, iStent
    • 0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space: initial device, Xen Gel Stent
    • 0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space, CyPass Micro-Stent

    Determination of coverage

    While the Relative Value Update Committee (RUC) reviews and values Category I CPT codes, it does not do so for Category III codes. That means no relative value units or payments are assigned to the physician. As a result, the payer has the discretion to determine coverage. Therefore, preauthorization is required.

    When preauthorizing, contact your commercial payer about the allowable amount. If the payer doesn’t allow anything, the patient will be responsible for surgeon and facility payments. It’s important, therefore, to notify the patient of all out-of-pocket expenses prior to surgery. You also may consider reaching out to the stent company, which may offer additional resources or support for reimbursement.

    For information about Medicare policy coverage and Category III codes, visit aao.org/lcds and aao.org/migs. Commercial plan coverage varies, so visit the specific payer website.  

    Modifiers

    Category III codes do not recognize modifiers other than -RT or -LT. As a result, the payer is likely to deny your claim if you append modifiers -53 (Discontinued procedure), -54 and -55 (Comanagement) or -79 (Unrelated) when the second eye undergoes surgery within the global period of the other eye.

    What Else Do You Need to Know?

    You must perform iStent and CyPass in conjunction with cataract surgery. Otherwise, the patient will be responsible for payment, even with a coverage policy. In addition, both the iStent and Xen Gel Stent Category III codes include “initial” phrasing in the descriptors. As such, each has an add-on code available for any additional stents that the ophthalmologist places during the initial surgery (see below).

    When payment is allowable for the first stent, Medicare will not cover second or subsequent stents for the same eye. Neither the payer nor the patient is responsible for payment of the surgeon’s fee for the additional stent(s). Commercial payers also may follow this coverage policy. However, when a payer does not have coverage for any stents, the patient will be responsible for the placement of primary stents as well as any additional stents.

    • +0376T Each additional device insertion for iStent (list separately in addition to code for primary procedure)
    • +0450T Each additional device insertion for Xen Gel Stent (list separately in addition to code for primary procedure)

    ICD-10 Recommendations

    The American Glaucoma Society recommends the following list of diagnoses codes. The AGS has provided guidelines on each stage:

    Mild- or early-stage glaucoma:

    • Optic nerve abnormalities consistent with glaucoma
    • but NO visual field abnormalities on any visual field test
    • OR abnormalities present only on short-wavelength automated perimetry or frequency-doubling perimetry

    Moderate-stage glaucoma:

    • Optic nerve abnormalities consistent with glaucoma
    • AND glaucomatous visual field abnormalities in ONE hemifield and NOT within 5 degrees of fixation (note: 5 degrees = involvement of spots nearest fixation)

    Advanced-, late- or severe-stage glaucoma:

    • Optic nerve abnormalities consistent with glaucoma
    • AND glaucomatous visual field abnormalities in BOTH hemifields
    • AND/OR loss within 5 degrees of fixation in at least one hemifield

    Note: Always follow your payer's policy as they will determine coverage. For MAC policies on MIGS, visit aao.org/LCDS.

    Recommended ICD-10 Codes of 0191T and 0474T:

    H40.10X1 Unspecified open-angle glaucoma, mild stage

    H40.10X2 Unspecified open-angle glaucoma, moderate stage

    H40.10X3 Unspecified open-angle glaucoma, severe stage

    H40.10X4 Unspecified open-angle glaucoma, indeterminate stage

    H40.1111 Primary open-angle glaucoma, right eye, mild stage

    H40.1112 Primary open-angle glaucoma, right eye, moderate stage

    H40.1113 Primary open-angle glaucoma, right eye, severe stage

    H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage

    H40.1121 Primary open-angle glaucoma, left eye, mild stage

    H40.1122 Primary open-angle glaucoma, left eye, moderate stage

    H40.1123 Primary open-angle glaucoma, left eye, severe stage

    H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage

    H40.1131 Primary open-angle glaucoma, bilateral, mild stage

    H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

    H40.1133 Primary open-angle glaucoma, bilateral, severe stage

    H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage

    H40.1211 Low-tension glaucoma, right eye, mild stage 

    H40.1212 Low-tension glaucoma, right eye, moderate stage

    H40.1213 Low-tension glaucoma, right eye, severe stage

    H40.1214 Low-tension glaucoma, right eye, indeterminate stage

    H40.1221 Low-tension glaucoma, left eye, mild stage

    H40.1222 Low-tension glaucoma, left eye, moderate stage

    H40.1223 Low-tension glaucoma, left eye, severe stage

    H40.1224 Low-tension glaucoma, left eye, indeterminate stage

    H40.1231 Low-tension glaucoma, bilateral, mild stage

    H40.1232 Low-tension glaucoma, bilateral, moderate stage

    H40.1233 Low-tension glaucoma, bilateral, severe stage

    H40.1234 Low-tension glaucoma, bilateral, indeterminate stage 

    H40.1311 Pigmentary glaucoma, right eye, mild stage

    H40.1312 Pigmentary glaucoma, right eye, moderate stage

    H40.1313 Pigmentary glaucoma, right eye, severe stage

    H40.1314 Pigmentary glaucoma, right eye, indeterminate stage

    H40.1321 Pigmentary glaucoma, left eye, mild stage

    H40.1322 Pigmentary glaucoma, left eye, moderate stage

    H40.1323 Pigmentary glaucoma, left eye, severe stage

    H40.1324 Pigmentary glaucoma, left eye, indeterminate stage

    H40.1331 Pigmentary glaucoma, bilateral, mild stage

    H40.1332 Pigmentary glaucoma, bilateral, moderate stage


    H40.1333 Pigmentary glaucoma, bilateral, severe stage

    H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage

    H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage

    H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage

    H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage

    H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage

    H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage

    H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage

    H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage

    H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage

    H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage

    H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage

    H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage

    H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage

    Recommended ICD-10 Codes for LCD coverage of XEN45 0449T:

    Medicare LCDs have thus far been written to restrict the use of Xen to cases of “refractory glaucoma.” Be sure to refer to the appropriate LCD for that payer’s specific definition of refractory glaucoma, and make sure that your clinical documentation addresses the criteria set forth in the document.

    H40.10X1 Unspecified open-angle glaucoma, mild stage

    H40.10X2 Unspecified open-angle glaucoma, moderate stage

    H40.10X3 Unspecified open-angle glaucoma, severe stage

    H40.10X4 Unspecified open-angle glaucoma, indeterminate stage

    H40.1111 Primary open-angle glaucoma, right eye, mild stage

    H40.1112 Primary open-angle glaucoma, right eye, moderate stage

    H40.1113 Primary open-angle glaucoma, right eye, severe stage

    H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage

    H40.1121 Primary open-angle glaucoma, left eye, mild stage

    H40.1122 Primary open-angle glaucoma, left eye, moderate stage

    H40.1123 Primary open-angle glaucoma, left eye, severe stage

    H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage

    H40.1131 Primary open-angle glaucoma, bilateral, mild stage

    H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

    H40.1133 Primary open-angle glaucoma, bilateral, severe stage

    H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage

    H40.1211 Low-tension glaucoma, right eye, mild stage 

    H40.1212 Low-tension glaucoma, right eye, moderate stage

    H40.1213 Low-tension glaucoma, right eye, severe stage

    H40.1214 Low-tension glaucoma, right eye, indeterminate stage

    H40.1221 Low-tension glaucoma, left eye, mild stage

    H40.1222 Low-tension glaucoma, left eye, moderate stage

    H40.1223 Low-tension glaucoma, left eye, severe stage

    H40.1224 Low-tension glaucoma, left eye, indeterminate stage

    H40.1231 Low-tension glaucoma, bilateral, mild stage

    H40.1232 Low-tension glaucoma, bilateral, moderate stage

    H40.1233 Low-tension glaucoma, bilateral, severe stage

    H40.1234 Low-tension glaucoma, bilateral, indeterminate stage 

    H40.1311 Pigmentary glaucoma, right eye, mild stage

    H40.1312 Pigmentary glaucoma, right eye, moderate stage

    H40.1313 Pigmentary glaucoma, right eye, severe stage

    H40.1314 Pigmentary glaucoma, right eye, indeterminate stage

    H40.1321 Pigmentary glaucoma, left eye, mild stage

    H40.1322 Pigmentary glaucoma, left eye, moderate stage

    H40.1323 Pigmentary glaucoma, left eye, severe stage

    H40.1324 Pigmentary glaucoma, left eye, indeterminate stage

    H40.1331 Pigmentary glaucoma, bilateral, mild stage

    H40.1332 Pigmentary glaucoma, bilateral, moderate stage


    H40.1333 Pigmentary glaucoma, bilateral, severe stage

    H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage

    H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage

    H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage

    H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage

    H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage

    H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage

    H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage

    H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage

    H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage

    H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage

    H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage

    H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage

    H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage

    H42 Glaucoma in diseases classified elsewhere

    For more on MIGS reimbursement, read EyeNet’s January Savvy Coder.

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    About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She also is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.