Four common SLT misconceptions
The reality: This therapy works for open-angle glaucoma.
By Nathan Radcliffe, MD
As an advocate of selective laser trabeculoplasty (SLT) to treat glaucoma, I frequently encounter colleagues’ misperceptions about the role SLT can and should play in managing this disease. Questions persist about when to use SLT, how payers view its use and what an SLT treatment plan looks like. In this article, I will discuss four common misconceptions of SLT and shed some light on how physicians can use this modality to help patients with glaucoma.
1. SLT is a last resort.
Several misconceptions surround the question, “When can you use SLT?” Many physicians think that SLT therapy is a last resort after medications have failed and that it should never be used as a primary therapy. In reality there are many indications for laser (sidebar). If we perform a history and physical examination on our patient and discover one of these indications (e.g., cost or compliance barriers or intolerance to certain agents), then that patient would be indicated for SLT regardless of where in the disease severity spectrum that patient may be.
I used to believe that SLT’s most fitting role was in patients who were maxed-out on eye drops. In my case, this belief was a carryover from the era of argon laser trabeculoplasty (ALT), which is a different treatment with different tissue endpoints and different outcomes — and, thus, a very different risk-benefit ratio. Whereas SLT is specific to pigmented cells, ALT is destructive to the tissue of the trabecular meshwork, with potential to cause necrotic death to the targeted and adjacent nonpigmented cells.1,2 SLT provides therapeutic benefit by using a shorter pulse duration and less energy delivery (0.6 to 1.2 mJ per pulse compared with the 40 to 70 mJ used with ALT).1,3 Correspondingly, SLT is a repeatable procedure4,5 and ALT is not.
As a result of the targeted energy delivery, and because it does not disqualify future treatment options, SLT has been shown to be effective for a wide range of patients, including treatment-naïve,6,7 those with normal tension glaucoma,8 pseudoexfoliation glaucoma,9 pigmentary dispersion syndrome10 and patients with anatomically small angles.11 Studies show that SLT is an effective primary therapy in appropriate patients, working as well as drops without the compliance issues or side effects such as ocular hyperemia and ocular surface disease.12,13
In my experience, SLT works best when used early in glaucoma’s early stages when the trabecular meshwork resists aqueous outflow. Current medical therapy aimed at increasing outflow functions primarily on the uveoscleral pathway; even in the case of the prostaglandin class, any effect on the trabecular meshwork is of secondary and lesser benefit. Future medical options may expand the ability to target different mechanisms of reduced aqueous outflow. However, at the moment, SLT is the only therapy that can reduce resistance and increase outflow through the trabecular pathway.14
2. SLT reimbursement is complicated.
The freedom to use SLT for different patient presentations and stages of treatment extends to payer reimbursements. The CMS reimburses “trabeculoplasty by laser surgery” (CPT code 65855) without consideration of disease severity or number of medications but instead to other common indications (see sidebar). In short, payer policies facilitate the data-supported use of SLT for appropriate patients at many places in the treatment algorithm and for many disease stages. From the payer’s perspective, SLT is a more cost-effective primary therapy than most eye drops, including generics, requiring fewer additional prescription medications and follow-up visits.15 For patients, the benefits from the laser may be priceless.
Pitfalls in SLT reimbursement
By Kevin J. Corcoran, COE, CPC, CPMA, FNAO
While selective laser trabeculoplasty (SLT) has been a covered procedure for treatment of open-angle glaucoma for many years, some confusion persists about reimbursement.1 Reviewing the coding, billing and charting fundamentals for SLT could help.
Medically necessary procedures
Trabeculoplasty performed with a frequency doubled Nd:YAG laser, known as SLT, is a covered procedure when it is medically necessary and supported in the patient’s medical record. SLT is indicated when a patient cannot tolerate anti-glaucoma medications or cannot comply with instructions for use.2,3 When anti-glaucoma meds aren’t affordable, SLT is a cost-effective alternative. Sometimes SLT will supplement a current medication to act as an adjunctive therapy, to prevent glaucomatous damage.
The eye exam that determines the need for SLT should list one or more reasons why the procedure should take place. Where an ophthalmologist or optometrist performs SLT more frequently than his peers, payers might challenge any reimbursement on the grounds that the procedure was not medically necessary. For example, an initial diagnosis of open-angle glaucoma would not typically justify SLT unless one of the considerations noted above was also present.
Repeat SLT
In clinical practice, SLT’s effectiveness can only be evaluated after one to two months, sometimes longer, which is far beyond the 10-day global period assigned by Medicare. When the surgeon believes additional treatment is medically necessary, outside of the global period, it is covered. Repeat treatments are supported in the literature.4,5 Even so, rates of retreatment are considerably different among physicians. At this year’s American Glaucoma Society conference, Joshua Stein, MD, and colleagues discussed a study that looked at Medicare data for laser trabeculoplasty (CPT 65855) performed in Oklahoma by optometrists and ophthalmologists.6
Oklahoma is one of the few states where optometrists are licensed to perform this procedure. The study found that optometrists were twice as likely to perform an additional laser trabeculoplasty on the same eye as ophthalmologists. The reasons for the difference were unclear, but it suggests that future payer policies may need to address this issue.
Same-day eye exam
Because the postoperative period for SLT is 10 days, it falls within Medicare’s payment rules for minor surgery. These rules differ from those for major surgery, which have a 90-day postoperative period. In particular, the visit on the day of a minor surgery is regarded as part of the global surgery package unless a separate, identifiable reason exists for the visit. If it does, the exam may be reportable with modifier 25. If the only reason for the visit is to determine the need for SLT, that visit is not separately billable.7
For many physicians, modifier 25 is automatically attached to any eye exam on the same day as a minor procedure to ensure payment. While reimbursement is probably justified in many cases, it is not universally warranted. According to the DHHS’ Office of Inspector General, modifier 25 is misused about 35% of the time.8
Postoperative care
In the first few days following SLT, an IOP spike is fairly common. This is generally managed with medication. An eye exam within 10 days of the laser trabeculoplasty that identifies an IOP spike is part of the global surgery package and not separate from it; no charge is warranted for medical management of an expected complication of the procedure in-office.
Contraindications for SLT
To perform SLT, the surgeon must be able to visualize the trabecular meshwork. Narrow angles, goniosynechiae and opaque corneas inhibit the view and contraindicate SLT. Further, a surgeon will not recommend a procedure with little or no hope of producing a benefit, so trabeculotomy, tube shunts or cyclodestructive procedures are likely a better option than SLT for those with advanced glaucoma.
Within the ICD-10 system for codifying diagnoses, it is possible to describe mild, moderate and severe glaucoma using the seventh character in the code. Although it takes some time to revise older local coverage policies to incorporate the new ICD-10 code set, new policies will likely incorporate the stage of the glaucoma disease as part of the definition of covered procedures. Billers should disseminate new coverage policies to physicians to clarify when SLT is covered by a limited set of ICD-10 diagnosis codes, and excludes others.
Medically unlikely edits (MUEs)
SLT may be performed as a bilateral procedure – both eyes on the same day. Under Medicare’s claims processing edits, there is a right way and a wrong way to submit the claim for the surgeon. CMS’ MUEs show a “1” for CPT 65855, which means that the number of units on the CMS-1500 claim form cannot exceed this value. So, if the biller uses two lines, 65855-RT and 65855-LT, with one unit for each line, then the total number of units on the claim is two, and the entire claim will fail. However, if the biller uses one line, 65855-50 with one unit, then the claim will process correctly. Attention to these details can save time and money for your practice.
Payment rates
Reimbursement declined for SLT in 2016. Medicare lowered its national payment rate for in-office SLT from $341 to $277, and SLT in an ASC or hospital outpatient department (HOPD) from $301 to $244. Correspondingly, the ASC national payment rate declined from $188 to $175, and the HOPD national payment rate declined from $443 to $440. This change coincides with the revision of the description in CPT for laser trabeculoplasty.
Prior to 2015, the phrase “one or more sessions” was part of the CPT code description. A year later, that phrase was removed, making it simpler to bill for each laser application.
Conclusion
Any confusion about reimbursement for SLT typically starts with the issues discussed in this article. Among all surgical treatments for glaucoma, laser trabeculoplasty is the most common by far, so pay close attention to charting, coding and billing for this service. OM
REFERENCES
1. Selective Laser Trabeculoplasty: 10 Commonly Asked Questions. Glaucoma Research Foundation. http://tinyurl.com/ne2hkwq. Accessed 10/20/16..
2. Iwach AG. Selective Laser Trabeculoplasty: Current Role in Glaucoma Management. AAO presentation 2012. Accessed 10/20/16.
3. Francis BA, Ianchulev T, Schofield JK, Minckler DS. Selective laser trabeculoplasty as a replacement for medical therapy in open-angle glaucoma. Am J Ophthalmol. 2005 Sep;140:524-525.
4. Lai J, Bournais TE. Repeatability of Selective Laser Trabeculoplasty (SLT). Invest Ophthalmol Vis Sci. 2005 May;46:119, E-abstract.
5. Hong BK, Winer JC, Martone JF, et al. Repeat selective laser trabeculoplasty. J Glaucoma. 2009 Mar; 18:180-183.
6. Stein J, Zhao P, Andrews C, Skuta G. A Comparison of Outcomes of Laser Trabeculoplasty Surgery Performed by Optometrists Versus Ophthalmologists in the State of Oklahoma. American Glaucoma Society Annual Meeting, March 2016.
7. Medicare Claims Processing Manual, Chapter 12, §30.6.6.B CPT Modifier 25.
8. Levinson D. Department of Health and Human Services Office of Inspector General, Use of Modifier 25, OEI-07-03-00470, November 2005. https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf. Accessed 10/20/16.
3. SLT must be performed unilaterally.
Some colleagues tell me that they only perform SLT unilaterally, based on safety or reimbursement concerns. However, IOP elevation after the laser is uncommon, and manageable if it does appear; it is also safe to perform bilateral same-day SLT. No clinical studies have reported systemic complications or associated inflammation, and the most common associated side effects are self-limited blurred vision and mild photophobia for the first two to three days after the procedure.
As for reimbursement, a bilateral procedure is eligible for 100% of the allowable reimbursement for the first eye and 50% for the second eye. The decision to perform SLT on one or both eyes in one day depends on the patient’s situation and the physician’s workflow, not the procedure’s safety or reimbursement. Some patients prefer to take it slowly, one eye at a time, and others want to do both at once, particularly if they have difficulty getting to the office.
4. SLT must be repeated every two years.
It is my belief that this misconception is a vestige of early guidelines for using SLT. Early studies suggested that the treatment effect of SLT lasted about two years16 — a guideline that somehow morphed into a belief SLT must be repeated every two years. While SLT is a repeatable procedure,4,5 studies have shown a treatment effect lasting as long as five years,17 and I have had some patients who are well-controlled 10 years after SLT.
I tell patients they may or may not need another SLT treatment, but we are fortunate to have a safe, effective repeatable therapy. They understand that SLT does not require a lifetime commitment to retreatment every two years.
A clearer view
SLT has earned a primary role in glaucoma management, where it can positively impact and, in all likelihood, permanently improve the overall course of the disease by treating the pathology without harming the eye. Eliminating misperceptions about the laser, and using it to its fullest potential, will certainly benefit physicians and patients alike. OM
REFERENCES
1. Abdelrahman AM. Noninvasive glaucoma procedures: current options and future innovations. MEAJO. 2015 Jan-Mar; 22: 2–9.
2. Kramer TR, Noecker RJ. Comparison of the morphologic changes after selective laser trabeculoplasty and argon laser trabeculoplasty in human eye bank eyes. Ophthalmology. 2001 Apr;108:773-779.
3. Latina MA, Sibayan SA, Shin DH, Noecker RJ, Marcellino G. Q-switched 532-nm Nd:YAG laser trabeculoplasty (selective laser trabeculoplasty): a multicenter, pilot, clinical study. Ophthalmology. 1998 Nov;105:2082-2088; discussion 2089-2090.
4. Hong BK, Winer JC, Martone JF, et al. Repeat selective laser trabeculoplasty. J Glaucoma. 2009 Mar;18:180-83.
5. Avery N, Ang GS, Nicholas S, Wells A. Repeatability of primary selective laser trabeculoplasty in patients with primary open-angle glaucoma. Int Ophthalmol. 2013 Oct;33:501-506.
6. Mao AJ, Pan XJ, McIlraith I, et al. Development of a prediction rule to estimate the probability of acceptable intraocular pressure reduction after selective laser trabeculoplasty in open-angle glaucoma and ocular hypertension. J Glaucoma. 2008 Sep;17:449-454.
7. Hodge WG, Damji KF, Rock W, et al. Baseline IOP predicts selective laser trabeculoplasty success at 1 year post-treatment: results from a randomised clinical trial. Br J Ophthalmol. 2005 Sep;89:1157-1160.
8. El Mallah MK, Walsh MM, Stinnett SS, Asrani SG. Selective laser trabeculoplasty reduces mean IOP and IOP variation in normal tension glaucoma patients. Clin Ophthalmol. 2010 Aug 9;4:889-893.
9. Bovell AM, Damji KF, Hodge WG, Rock WJ, Buhrmann RR, Pan YI. Long term effects on the lowering of intraocular pressure: selective laser or argon laser trabeculoplasty? Can J Ophthalmol. 2011 Oct;46:408-413
10. Ayala M. Long-term outcomes of selective laser trabeculoplasty (SLT) treatment in pigmentary glaucoma patients. J Glaucoma. 2014 Dec;23:616-619.
11. Narayanaswamy A, Leung CK, Istiantoro DV, et al. Efficacy of selective laser trabeculoplasty in primary angle-closure glaucoma: a randomized clinical trial. JAMA Ophthalmol. 2015 Feb;133:206-212.
12. Waisbourd M, Katz LJ. Selective laser trabeculoplasty as a first-line therapy: a review. Can J Ophthalmol. 2014 Dec;49:519-522.
13. Katz LJ, Steinmann WC, Kabir A, et al; SLT/Med Study Group. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012 Sep;21:460-468.
14. Beltran-Agullo L, Alaghband P, Obi A, et al. The effect of selective laser trabeculoplasty on aqueous humor dynamics in patients with ocular hypertension and primary open-angle glaucoma. J Glaucoma. 2013 Dec;22:746-749.
15. Seider MI, Keenan JD, Han Y. Cost of selective laser trabeculoplasty vs topical medications for glaucoma. Arch Ophthalmol. 2012 Apr;130:529-530.
16. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: a prospective, nonrandomized pilot study. Arch Ophthalmol. 2003 Jul;121:957-960.
17. Jindra LF, Gupta A, Miglino EM. Poster presented at the American Academy of Ophthalmology Annual Meeting, November 2007.
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About the Author |
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Nathan Radcliffe, MD, is director of the Glaucoma Service and is clinical assistant professor at New York University Langone Ophthalmology Associates. |
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