This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS).
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Specific Coding Guideline:
According to Current Procedural Terminology (CPT), in this setting a 'device' is a 'stent'. Therefore, to comply with coverage requirements set forth in the Local Coverage Determination the stent(s) must be inserted on the same date of service as the cataract surgery and billed accordingly on the same claim.
Insertion of these devices not in conjunction with cataract surgery services is considered investigational and will be denied.
For insertion of the XEN45 bill 0449T. Insertion of more than one XEN45 device per eye in a given surgical session (each additional device represented by CPT 0450T) is considered investigational and not covered.
Since there is no specific CPT® code for goniopuncture or so-called microgoniotomy procedures, the unlisted CPT® code 66999 (unlisted procedure, anterior segment of the eye) should be reported in these instances.
Any procedures performed which consists of single or multiple small punctures and/or injections of small amounts of viscoelastic, or other limited interventions should be reported using unlisted CPT® code 66999.
Specifically, goniotomy (CPT® code 65820) should not be coded in addition to other angle surgeries, stent insertions or Schlemm canal implants or if the incision into the trabecular meshwork is minimal or simply incidental to another procedure.
In order to report a goniotomy, an extensive incision of the trabecular meshwork around the eye, at the least and generally more than 3 clock hours, must have been performed.
Documentation regarding the reasonable and necessary premise for the work must be present. Noridian may request additional documentation on a case-by-case basis.
Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included in the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The medical record and/or test results documenting medical necessity should be maintained and made available on request. iStent, iStent inject, and Hydrus must be performed in conjunction with cataract surgery on the same date of service and documented in the medical record.
