Goniotomy is not a common procedure in ophthalmology, but is a useful part of the surgeon’s armamentarium for certain types of glaucoma. Here are the essentials of coding for it.

Q. What is trabeculotomy ab interno, also known as goniotomy?

A. Trabeculotomy ab interno is an ophthalmic surgical procedure to incise and partially remove trabecular meshwork in order to create an opening into Schlemm’s canal by way of the anterior chamber angle. The surgeon uses an ab interno approach from inside the anterior chamber under indirect visualization with a goniolens. So, the longstanding term for this procedure is “goniotomy.”

The primary indication for goniotomy is to clear the obstruction to aqueous outflow and associated abnormal internal drainage, which in turn lowers the intraocular pressure. Goniotomy is primarily performed to treat congenital glaucoma.

Other indications include: aniridia, uveitic glaucoma associated with juvenile rheumatoid arthritis, juvenile open-angle glaucoma and other abnormalities that create a blockage in trabecular meshwork.

In order to perform the surgery, the surgeon must clearly visualize the angle structures; good corneal clarity is required. An inability to see the anterior chamber angle, therefore, is a contraindication to goniotomy.

Q. Can I use goniotomy as a primary or first-line line treatment for congenital glaucoma?

A. Yes. According to the guidelines from the American Academy of Ophthalmology, the primary treatment for congenital glaucoma is angle surgery, either goniotomy or trabeculotomy ab externo, and “[g]oniotomy is preferred when the cornea is clear enough to permit visualization of anterior segment structures.”¹

Q. What CPT code describes trabeculotomy ab interno or goniotomy?

A. Use CPT 65820 (Goniotomy). CPT 65820 is considered a major surgical procedure; CMS defines it as having a 90-day postoperative period.

CPT also instructs: “For use of ophthalmic endoscope with 65820, use 66990.”² Ophthalmic endoscopy is defined in CPT as +66990. The “+” indicates an add-on code, which is not subject to the multiple procedure rule. Only a few ophthalmic procedures are eligible to be billed with +66990 — goniotomy is one of those.

It adds about $92 to the surgeon’s reimbursement.

It is important to note that trabeculotomy ab externo (CPT 65850) is not equivalent to trabeculotomy ab interno — the surgical approach to Schlemm’s canal differs. Be careful not use CPT 65850 for an ab interno procedure.

Q. What is the Medicare physician reimbursement for goniotomy?

A. The 2017 national Medicare Physician Fee Schedule (MPFS) allows $760 for goniotomy. This amount is adjusted by local indices, so actual payment amounts vary. Other third-party payers set their own rates.

Q. Does Medicare allow a facility fee for goniotomy performed in an ASC or HOPD?

A. Under current Medicare regulations, 65820 is eligible for a facility fee. The national 2017 ambulatory surgery center allowed amount is $1,747; in the hospital outpatient department (HOPD), the allowable is $3,417. Allowed amounts are adjusted by local indices.

ASC: As with physician payment rules when goniotomy and another major ophthalmic surgery are performed in the same operative session in an ASC, then the multiple procedure rules apply, and so reimbursement for the second procedure is reduced by 50%.

HOPD: Payment rules are different for the HOPD. When goniotomy and another major ophthalmic surgery are performed in the same operative session in an HOPD, the multiple procedure rule does not apply. Goniotomy is assigned a J1 indicator and classified in APC 5492, a comprehensive APC.

All covered Part B services on the claim are packaged with the primary J1 service for reimbursement; there are only a few exceptions.

Q. Is goniotomy bundled with other services?

A. Yes. (See Chart, this page.) According to Medicare’s National Correct Coding Initiative (NCCI), 65820 is bundled with some ophthalmic procedures, although not with cataract surgery. For example, goniotomy and endocyclophotocoagulation (ECP, 66711) are bundled. Check the NCCI edits for details. OM

REFERENCES

1. Clark, RA. Glaucoma, Congenital Or Infantile. EyeWiki. http://eyewiki.org/Glaucoma,_Congenital_Or_Infantile Last modified Sept. 30, 2014. Accessed February 1, 2017.
2. American Medical Association. Current Procedural Terminology (CPT). 2016.

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