Coding & Reimbursement: Navigating New Coverage Challenges for MIGS

By: Brittney Irwin, COT, CPC, CEP, Kirk Mack, COMT, COE, CPC, CPMA

Ophthalmology Management March 1, 2025 Vol 30, Issue March 2025 Page(s): 9

Clinical Report: Coding & Reimbursement for MIGS in 2024

Overview

In 2024, five Medicare Administrative Contractors (MACs) revised coverage policies for microinvasive glaucoma surgery (MIGS) on November 17, clarifying limitations and coding guidance.

Background

The management of glaucoma is critical due to its potential to cause irreversible vision loss. Microinvasive glaucoma surgery (MIGS) has emerged as a less invasive option for patients, particularly during cataract surgery. Understanding the evolving coverage policies from MACs such as Palmetto, NGS, CGS, Noridian, and WPS is essential for healthcare providers to navigate reimbursement challenges and ensure appropriate patient care.

Data Highlights

Key findings indicate that five MACs implemented updated local coverage determinations (LCDs) for MIGS, specifying that it is not a first-line treatment for mild to moderate glaucoma and restricting coverage to a single MIGS procedure per session.

Key Findings

Five MACs implemented updated local coverage determinations (LCDs) for MIGS on November 17, 2024. MIGS is not considered a first-line treatment for mild to moderate glaucoma according to the updated policies. Coverage for multiple MIGS procedures performed in a single session is restricted, with claims likely to be denied. Proper documentation of patient compliance with ocular hypotensive medications is essential for coverage eligibility. Commercial payers are also reviewing their MIGS policies, which may differ from Medicare's guidelines.

Clinical Implications

Healthcare providers must be aware of the updated policies regarding MIGS to ensure compliance and optimize reimbursement. Emphasizing proper documentation of medical necessity, patient adherence to treatment regimens, and patient-specific factors will be crucial in navigating these new coverage challenges.

Conclusion

The revised coverage policies for MIGS highlight the need for careful patient selection and thorough documentation to meet Medicare's criteria for surgical intervention. Ongoing updates from commercial payers will further influence the landscape of MIGS reimbursement, necessitating vigilance from healthcare providers.

PentaVision

Ophthalmology Management