Coding & Reimbursement

When ECP is your choice

It’s an uncommon procedure, but you might have to bill for it some day.

By Suzanne L. Corcoran

When glaucoma medications fail or the patient cannot tolerate them, surgeons have various surgical procedures they can turn to — and then bill for. Here’s help with the latter task for one glaucoma surgery option when others have failed: endoscopic cyclophotocoagulation.

Q. What is endoscopic cyclophotocoagulation?

A. Endoscopic cyclophotocoagulation (ECP) uses a laser endoscope to precisely deliver laser energy to the ciliary processes. Using this approach limits damage to the underlying ciliary body and surrounding tissue.¹ The procedure minimizes the disadvantages of transscleral cyclodestructive procedures while maximizing the advantage of ablating the ciliary body epithelium to decrease IOP.

Illustration of ECP following cataract surgery

Q. What are the indications?

A. According to the guidelines from the American Academy of Ophthalmology and others,² patients with the following indications may undergo ECP:

1. Refractory glaucoma who have failed trabeculectomy or tube shunt procedures; or

2. Minimal useful vision and elevated, poorly controlled, IOP (even with multiple medications) with or without cataracts; or

3. Complicated, advanced glaucoma and conjunctival scarring from previous surgery; or

4. In general medical conditions that preclude invasive surgery or who refuse more aggressive surgery (i.e., filter or tube shunt), or

5. In emergency situations, such as the acute onset of neovascular glaucoma.

Q. Is ECP used as a primary or initial line of treatment for glaucoma?

A. Rarely. When it is, the medical record must include an explanation why the surgeon deviated from the standard of care and why medical treatment was not attempted first. Traditionally, the medical necessity for surgery depends on the failure or contraindication of pharmaceuticals.³

Q. Does Medicare cover ECP alone or with cataract surgery?

A. ECP of the ciliary body performed with a diode laser is a covered procedure when it is medically necessary. Combining treatment of cataract and glaucoma in the same operation, when medically appropriate, is likewise covered.⁴

Q. Which CPT code describes ECP?

A. Use CPT code 66711 (ciliary body destruction; cyclophotocoagulation, endoscopic). ECP is considered a major surgical procedure with a 90-day postoperative period.

Q. ECP uses an endoscope to perform the procedure. Is 66990 payable with 66711?

A. No. CPT specifically designates which codes are eligible for the add-on code, 66990, use of ophthalmic endoscope. Code 66711 is not listed, and CPT instructs coders not to do so. In addition, Medicare’s National Correct Coding Initiative (NCCI) bundles 66990 with 66711, which yields the same result.

Q. What is the Medicare reimbursement?

A. The current national Medicare Physician Fee Schedule allows $651.83 for ECP. Medicare also allows a facility fee for 66711; it is paid under ambulatory payment classification 233, as is cataract surgery. The 2015 national ambulatory surgery center (ASC) allowed amount is $960.64; in the hospital outpatient department (HOPD), the allowable is $1,752.62.

For both physicians and facilities, allowed amounts are adjusted by local indices. In addition, Medicare’s multiple surgery rules apply; the second procedure is reduced by 50%.

Q. Can 65875 (severing posterior synechiae) be billed with 66711, since the iris is lifted with viscoelastic?

A. No. ECP requires the use of viscoelastic to elevate the iris and provide access to the ciliary processes; breaking posterior synechiae (if any) is an incidental part of ECP. Furthermore, Medicare’s NCCI bundles 65875 with 66711, so no separate reimbursement is available.

Q. How often is ECP performed on Medicare beneficiaries?

A. Of all glaucoma procedures performed on Medicare beneficiaries in calendar year 2013, the most recent year for which data are available, 3% were ECP. OM

REFERENCES

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