Coding & Reimbursement

Coding a Glaucoma Solution

Canaloplasty billing tips.

By Suzanne L. Corcoran, COE

New surgical procedures for glaucoma are being developed more frequently, to the advantage of surgeons and patients. One of particular interest is known as canaloplasty.

Q. What is canaloplasty? Canaloplasty is a microcatheter-based interventional surgery for open-angle glaucoma. A flexible microcatheter is placed in Schlemm's canal via a scleral cut down. Intraoperative ultrasound imaging guidance is commonly used to ensure proper catheterization. The microcatheter is navigated for 360° through Schlemm's canal, then the surgeon attaches a 10-0 polypropylene suture to the microcatheter and draws it through Schlemm's canal as the microcatheter is retracted. The suture is tied off in a loop to distend the trabecular meshwork, with the desired outcome being dilation of the drainage system and increased outflow.

Canaloplasty is indicated for patients with open-angle glaucoma in several circumstances:

► Uncontrolled open-angle glaucoma refractory to anti-glaucoma medications

► Primary open-angle glaucoma mixed with exfoliation or pigmentation glaucoma refractory to anti-glaucoma medications

► Pseudoexfoliative and pigmentary glaucoma that is refractory to anti-glaucoma medications

► Failed laser trabeculoplasty without scarring

► Cases when target IOP is unlikely to be achieved with medication alone

Canaloplasty is contraindicated in the following circumstances:

► Eyes with narrow-angle glaucoma

► Eyes with steep peripheral or plateau iris

► Eyes with angle-closure glaucoma

► Eyes with peripheral anterior synechiae

► Eyes with chronic inflammation or neovascularization

► Eyes with secondary glaucoma following gross trauma

► Prior trabeculectomy or other procedure which would prevent full 360° cannulation of Schlemm's canal

► Prior implantation of an aqueous shunt

► Prior laser trabeculoplasty with scarring

► Patients who cannot comply with postoperative instructions (i.e., poor mentation)

► Any ophthalmic surgeon who is not formally trained to perform canaloplasty or other non-penetrating procedures that access Schlemm's canal.

Q. What CPT code describes canaloplasty? Effective Jan. 1, 2007, there are two Category III CPT codes that describe interventional glaucoma surgery:

► 0176T. Transluminal dilation of aqueous outflow canal; without retention of device or stent

► 0177T. Transluminal dilation of aqueous outflow canal; with retention of device or stent

Canaloplasty, using polypropylene suture, is best described by 0177T.

Q. Are these procedures covered by Medicare and other third-party payers? Sometimes. Because coverage policies vary and do not typically exist for new procedures, we recommend obtaining prior authorization from the payer on a case-by-case basis whenever possible. Before surgery, ask the patient to agree to be financially responsible if reimbursement is not forthcoming. Obtain the patient's signature on an Advance Beneficiary Notice (ABN) for Medicare patients or on another suitable waiver form for other payers. The surgeon and the facility should each obtain the signed forms independently.

Q. When the procedures are covered, how are they reimbursed? For the surgeon, Medicare does not assign relative value units or a dollar value to Category III CPT codes. Reimbursement is determined on a case-by-case basis at the discretion of the payer. For the sake of reference, code 66170 or 66172 provide a useful starting point for establishing a value, although they may not be used to describe the procedures.

In an ambulatory surgery center (ASC), canaloplasty has been assigned to Group 9. In 2007, the national Medicare rate for Group 9 is $1,339.

For hospital outpatient departments, canaloplasty is assigned to Ambulatory Payment Classification (APC) 0673; the 2007 national Medicare rate is $2,329.

Note that assignment to an ASC group or APC does not guarantee payment. Just as they are for the physician, claims for Category III CPT codes are adjudicated on a case-by-case basis. OM