Glaucoma coding: 2015 brings changes

Brace yourselves for reductions.

By Suzanne L. Corcoran, COE

This month, I will tackle what practices face in the new year with regard to changes to glaucoma coding. For 2015, coding and reimbursement for tube shunt procedures will change significantly — and not in ways glaucoma specialists will appreciate. The result is an overall reduction in Medicare reimbursement.

SHUNT UPDATE

Implantation of an aqueous shunt to extraocular reservoir, such as Ahmed Glaucoma Valve (New World Medical, Inc.), Baerveldt Glaucoma Implant (Abbott Medical Optics), and similar devices, frequently requires the use of a patch graft, especially for patients with scleromalacia (379.04), scleral ectasia (379.11), degenerative scleral disease (379.16), or a mechanical complication such as conjunctival erosion due to a previous shunt (996.59). Prior to 2015, practices had one code to describe implantation of an aqueous shunt to extraocular reservoir (66180) and one code to describe a revision procedure (66185). When a patch graft was required with either procedure, it was billed separately as 67255 (scleral reinforcement with graft).

Payers reimbursed based on 100% of the Medicare Physician Fee Schedule (MPFS) allowed amount for the first (greater valued) procedure and, in accordance with Medicare’s multiple procedure rules, based on 50% for the second (lesser valued) procedure. National MPFS allowed amounts in 2014 are shown in Table 1.

For example, in 2014 CMS allowed a surgeon $1,214.03 plus $447.25 for 66180 and 67255 performed in the same operating session.

As of January 1, 2015, there are new or revised pertinent CPT codes. See the codes and their 2015 National Medicare allowed amounts in Table 2.

The change in CPT means you may not report 67255 with 66180 or 66185; a patch graft is now explicitly part of the code description. These changes reduce payment to the surgeon by about 30%, as shown in Table 3. CMS has also reduced facility payments.

AND THAT’S NOT ALL

See other changes (Table 4) to 2015 national MPFS allowed amounts affecting physicians who treat glaucoma. It is noteworthy that Table 4 omits a Category III CPT code for minimally invasive glaucoma surgeries (MIGS), 0191T, because it is absent from MPFS.

The small reduction (1%-2%) for eye exams and most diagnostic tests occurred because of an error in prior years in the relative value units (RVUs) assigned to malpractice expense, which CMS is correcting in 2015.

UTILIZATION TRENDS

Based on CMS Part B data for paid claims, Corcoran Consulting Group analyzed changes in utilization for glaucoma surgical procedures. Over the past five years, the total number of glaucoma surgeries of all types performed on Medicare Part B beneficiaries has remained fairly constant, around 350,000 per year. Among the top 10 glaucoma surgical procedures, the number of operations involving aqueous drainage devices such as tube shunts (66180), EX-PRESS mini-glaucoma shunt (Alcon) (0192T, 66183), and iStent trabecular micro-bypass stent (Glaukos) (0191T) increased significantly.

At the same time, the frequency of trabeculectomy (66170, 66172) decreased, a development consistent with the findings of many clinical studies comparing the procedure with aqueous drainage devices. Laser procedures, such as trabeculoplasty (65855) and peripheral iridotomy (66761), were largely unchanged.

The changes to the MPFS will probably not impact trabeculectomy and laser procedures to any major degree, but the significant reduction in reimbursement for tube shunt procedures could provide an incentive to perform MIGS procedures. OM

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