Coding & Reimbursement

Goniopuncture Know-How

By Suzanne L. Corcoran, COE

Glaucoma is a difficult disease to treat successfully — some treatments only work for a while and then fail. Intraocular pressure may rise again to unacceptable levels in some patients, and an additional surgical procedure may be required; goniopuncture is one choice. Here are its coding basics.

Q. What is goniopuncture?

A. Goniopuncture is a procedure performed using the Nd:YAG laser to improve aqueous outflow through Descemet's window. Goniopuncture is indicated for glaucomatous patients who have undergone surgery but whose IOP remains too high. Goniopuncture may lower IOP without the need for a more invasive procedure. One or more openings are made in Descemet's window with the laser, using a goniolens for visualization. As always, the intent is to lower intraocular pressures.

Q. What CPT code is used to report goniopuncture?

A. CPT 66250, “Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure” describes goniopuncture following a prior surgery, most commonly canaloplasty or implantation of a stent or other device.

Q. What should the surgeon's operative report contain?

A. All of the following elements should be included in the surgeon's report:

• The surgeon's assessment that the IOP is not adequately controlled by the prior surgery.
• Creation of one or more openings in Descemet's window is expected to increase aqueous egress and lower the IOP.
• Fenestration of Descemet's window using Nd:YAG photoablation will create the openings.

Q. What is the physician reimbursement for 66250?

A. There are a number of issues that affect reimbursement.

• Whether the patient is inside or outside of the global period for the prior surgery.
• Whether the procedure takes place in the office or in a facility.

Outside of the global period, the 2012 national Medicare Physician Fee Schedule (MPFS) allowable is $751 in a physician's office, and $564 when done in a facility. Within the global period, the 2012 national MPFS allowable is $525 in a physician's office, and $395 when done in a facility. Modifier 78 is responsible for this reduction.

Q. What is modifier 78?

A. Modifier 78 is defined in CPT as an unplanned return to the operating room for a related procedure during the postoperative period: “Unplanned return to the operating/procedure room by the same physician … following initial procedure for a related procedure during the postoperative period.”

CPT goes on to explain: “It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.” Within the Medicare system, modifier 78 reduces the payment as noted above.

Q. Would a laser suite located in a physician's office qualify as an OR for this purpose?

A. Usually. The Medicare Claims Processing Manual (MCPM), Chapter 12, §40.1B, defines, “An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, an intensive care unit…” [Emphasis added.]

Q. Does payment change if the goniopuncture is performed by someone other than the surgeon who performed the original procedure?

A. If the surgeon who performs the goniopuncture is not in the same group as the surgeon who performed the prior surgical procedure, then modifier 78 does not apply. If goniopuncture is performed by the same surgeon or another surgeon in the same group, within the postoperative period, modifier 78 applies.

The MCPM Chapter 12, §40.2.A.2 states: “When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group.”

Q. What is the facility reimbursement for 66250?

A. The 2012 national Medicare facility reimbursement for an ambulatory surgery center (ASC) is $670. For a hospital outpatient department (HOPD), the amount is $1,164. These amounts are adjusted by local indices. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.