Understand changes in cataract and MIGS combined codes and payer policies.

Recent coding updates for microinvasive glaucoma surgeries (MIGS), including changes to Current Procedural Terminology (CPT) Category I and Category III codes, have raised questions among some ophthalmologists and payers. Beginning last year, the Category III codes 0191T and +0376T were replaced by the Category I codes 66989 and 66991 and the Category III code 0671T (Table 1). The introduction of these new codes prompts careful consideration when performing combination procedures involving cataract surgeries and the insertion of MIGS devices.¹

When combining cataract surgery with the insertion of devices like Hydrus Microstent (Alcon) or the iStent, iStent Infinite, or iStent Inject (Glaukos), physicians and ASCs must choose the appropriate new code based on the complexity of the cataract surgery. The new CPT code 66991 is used for standard cataract surgeries accompanied by inserting one of the stents listed above, while 66989 is applicable to complex cases. The CPT codes reported by physicians and ASCs for the same surgery should always match.

The Category III code 0671T should be used for standalone insertion of a stenting device into the trabecular meshwork (TM). Currently, iStent Infinite is the only FDA-approved standalone procedure for glaucoma. The other TM stent devices are only approved in combination with cataract surgery.

When the Xen gel stent (Allergan) is inserted with cataract procedures, use Category III code 0449T with 66984 (standard) or 66982 (complex). Standalone Xen insertion varies: if an ab interno approach, use 0449T; for ab externo placement, use 66183. Make sure the operational report aligns with the CPT code description.

CATARACT, ECP, AND MIGS

When endoscopic cyclophotocoagulation (ECP) of the ciliary processes is performed to reduce the secretion of aqueous humor in glaucoma during the same surgical procedure as cataract surgery, the new codes 66989 and 66991 are not used. Instead, use CPT code 66987 for complex cataracts with ECP or 66988 for standard surgery with ECP.

MIGS and ECP are not standalone procedures when combined with cataract surgery, so it’s not appropriate to report code 0671T for the stent procedure or to use the standalone CPT code for ECP, 66711. Instead, if the surgeon combines ECP with MIGS device insertion during cataract surgery, there are two ways the procedure can be appropriately coded and billed:

• Option 1: Use CPT code 66999 (Unlisted procedure, anterior segment of eye) for combined cataract, MIGS, and ECP procedures; or
• Option 2: Submit 66989 (complex cataract surgery) or 66991 (standard cataract surgery) for the cataract and MIGS components and append modifier -22 (increased procedural services) for the ECP component.

Obtaining preauthorization is crucial, particularly for complex cataract surgeries, as the need for such complexity might not always be apparent preoperatively. Seeking preauthorization for both standard and complex surgery codes when standalone or in combination with either MIGS or ECP surgeries ensures that the billing process remains smooth. It’s also essential to be mindful of each payer’s allowable reimbursement for the newly introduced codes, as these values can vary across different insurance providers. Staying informed about reimbursement rates aids in accurate financial planning for ophthalmic ASCs.

HCPCS AND DIAGNOSIS CODES

In addition to the procedure codes, certain ASC claims submitted to commercial payers might necessitate the incorporation of a Healthcare Common Procedure Coding System (HCPCS) code. It is advisable for ASCs to thoroughly examine their provider contracts with payers to obtain appropriate HCPCS billing guidance.

Diagnosis coverage for MIGS procedures is payer specific. Always ask and answer the questions related to who the payer is and what their published policies entail. For example, Noridian’s MIGS diagnosis coverage includes the following:

• Primary open angle glaucoma, mild, moderate, and severe stages (H40.11XX)
• Low-tension glaucoma mild, moderate, and severe stages (H40.11XX)
• Pigmentary glaucoma mild, moderate, and severe stages (H40.13XX)
• Capsular glaucoma with pseudoexfoliation of lens, mild, moderate, and sever stages (H40.14XX)²

The physician ultimately is responsible for documenting the ICD-10-CM diagnosis code that best represents the patient’s medical condition. Diagnosis codes on the claim forms for the same surgical session for the physician and ASC should match.

CONCLUSION

The coding and policy changes that took effect in 2022 have introduced complexities and challenges in glaucoma surgery billing. ASCs must familiarize themselves with the updated codes, understand the nuances of combination procedures, and stay informed about evolving payer policies. Adapting to these changes ensures accurate billing, optimal reimbursement, and high-quality patient care in the realm of glaucoma surgeries. ■

REFERENCES

1. Glasser, DB, Repka MX, Vicchrilli S. “MIGS Update—How to Code for Combined Glaucoma Procedures.” Eyenet. March 2022. Accessed August 24, 2023. https://www.aao.org/eyenet/article/migs-update-code-combined-glaucoma-procedures?march-2022
2. Centers for Medicare and Medicaid Services. “Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS).” Revised October 3, 2022. Accessed August 24, 2023. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57863