Abstract:
Glaucoma filtering surgery is indicated when glaucomatous damage progresses despite pharmacological and/or surgical treatment. Trabeculectomy is the most widely used form of filtering surgical treatment for primary open-angle glaucoma. Glaucoma drainage implants designed to shunt the aqueous fluid posteriorly represent an alternative method for lowering intraocular pressure in glaucomatous patients and are commonly used in refractory glaucoma or after failure of filtration surgery.
Since the first mini shunt device was approved by the Food and Drug Administration (FDA) for marketing in March 2002, over 14,000 implantations have been performed. However, there has been disagreement in the ophthalmology community regarding the correct coding for this procedure. The majority of ophthalmologists billed Current Procedural Terminology (CPT) code 66180 (Aqueous shunt to extraocular reservoir [eg, Molteno, Schocket, Denver-Krupin]), with some using 66172 (Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma [includes injection of antifibrotic agents]) or 66999 (Unlisted procedure, anterior segment of eye). Because of this disagreement, the American Medical Association (AMA) CPT Panel developed a new Category III CPT code, 0192T (Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach), effective for services rendered on or after July 1, 2008 thru December 31, 2013. Effective January 1, 2014 CPT code 66183 should be used for the insertion of anterior segment aqueous drainage device.. The appropriate ICD-10-CM codes are listed below in the covered ICD-10 code section. The device used must be FDA approved, such as the Ex-PRESS™ mini shunt (Optonol).
Indications:
An anterior segment aqueous drainage device, without extraocular reservoir, implanted under a partial thickness scleral flap may be a safe alternative or adjunct to standard guarded trabeculectomy, especially for patients with advanced glaucoma in need of low intraocular pressures with a high risk for hypotonous complication.
Limitations:
Other indications for 0192T and/or 66183 remain investigational or not medically necessary.
Coding Guidelines:
General Guidelines for claims submitted to Part A or Part B MAC:
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.
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
The anatomic modifiers left (-LT) or right (-RT) should be appended to the procedure code. The -50 modifier is not to be appended to this code as two eyes should not be done on the same day.
Only CPT code 0192T should be reported for insertion of the anterior segment aqueous drainage device for dates of service July 1, 2008 thru December 31, 2013. Effective January 1, 2014 CPT code 66183 should be reported for insertion of the anterior segment aqueous drainage device. . Do not report CPT codes 66170, 66172, 66180 or other procedure codes formerly used for the insertion of this device.
For claims submitted to the Part B MAC:
Claims for 0192T/66183 are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24) and independent clinic (49).
For claims submitted to the Part A MAC:
Hospital Inpatient Claims:
- The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
- The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
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- For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
- The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
- The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
