DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

DA57863

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
A57863
Draft Article ID
DA57863
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
ANTICIPATED 09/09/2025

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CMS National Coverage Policy

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Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to Local Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS).

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Coding Guidance

For noncomplex cataract removal with insertion of aqueous drainage system, use CPT 66991.

For complex cataract removal with intraocular lens implant and concomitant intraocular aqueous drainage device, use CPT code 66989.

Please refer to the "Limitations" section in the related LCD for additional information.

For Part A claims:

  • Line SV202-7 for 837I electronic claim
  • Block 80 for the UB04 claim form

For Part B claims:

  • Loop 2400 or SV101-7 for the 5010A1 837P
  • Box 19 for paper claim

CPT code 65820 Goniotomy

Goniotomy is a procedure in which trabecular meshwork is incised and/or excised with a blade or other surgical instrument for at least three clock hours to create an opening into Schlemm canal from the anterior chamber, via an internal approach through the anterior chamber and is reported with CPT code 65820.

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. Performing multiple goniopunctures with or without excision of tissue does not meet the CPT® description for a true goniotomy.

Goniotomy 65820 is per eye. For Medicare Part B patients, when a surgery is performed bilaterally, submit one line item with the surgical code appended by modifier -50, per Medically Unlikely Edits (MUEs) effective April 1, 2013. A “1” should be placed in the unit field and the charge should be doubled.

Effective July 1, 2020, 65820 is bundled with 66174. Both procedures cannot be reported together.

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 and the procedure performed identified within the narrative.

Frequency Limitations

Medicare may cover only 1 unit per eye, per date of service of CPT code 66991 and 66989 for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent®) when performed in conjunction with cataract surgery on the date of service and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, using an insertion tool loaded with more than one device, (e.g., iStent inject®), may be performed, once the insertion tool is deployed within the eye, there is negligible increase in work or expense. Therefore, only one unit of 66991 and 66989 per eye, per day may be billed, regardless of the number of devices inserted into a single eye on the date of service.

Medicare may cover only 1 unit per eye, per date of service of CPT code 0449T or 0671T for insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45®, iStent Infinite®), when the medically reasonable and necessary criteria as stated in the LCD are met.

Multiple Procedure Limitations

Phacoemulsification can be performed in conjunction with a single glaucoma lowering procedure, stent device or surgical.

Reporting of a combination of MIGs procedures (other than phacoemulsification) at the same time of service in the same patient risks denial of the entire claim. A combination of services is more than one device or surgical technique applied at the same time.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request.
  2. The documentation must include previous treatments and response to the treatment.
  3. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  4. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(7 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT codes 66989 and 66991.

 

Group 1 Codes
Code Description
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

Group 2

(52 Codes)
Group 2 Paragraph

Medicare is establishing the following limited coverage for CPT code 0449T (XEN) and 0671T:

Group 2 Codes
Code Description
H40.10X1 Unspecified open-angle glaucoma, mild stage
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.10X3 Unspecified open-angle glaucoma, severe stage
H40.10X4 Unspecified open-angle glaucoma, indeterminate stage
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1113 Primary open-angle glaucoma, right eye, severe stage
H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage
H40.1133 Primary open-angle glaucoma, bilateral, severe stage
H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1211 Low-tension glaucoma, right eye, mild stage
H40.1212 Low-tension glaucoma, right eye, moderate stage
H40.1213 Low-tension glaucoma, right eye, severe stage
H40.1214 Low-tension glaucoma, right eye, indeterminate stage
H40.1221 Low-tension glaucoma, left eye, mild stage
H40.1222 Low-tension glaucoma, left eye, moderate stage
H40.1223 Low-tension glaucoma, left eye, severe stage
H40.1224 Low-tension glaucoma, left eye, indeterminate stage
H40.1231 Low-tension glaucoma, bilateral, mild stage
H40.1232 Low-tension glaucoma, bilateral, moderate stage
H40.1233 Low-tension glaucoma, bilateral, severe stage
H40.1234 Low-tension glaucoma, bilateral, indeterminate stage
H40.1311 Pigmentary glaucoma, right eye, mild stage
H40.1312 Pigmentary glaucoma, right eye, moderate stage
H40.1313 Pigmentary glaucoma, right eye, severe stage
H40.1314 Pigmentary glaucoma, right eye, indeterminate stage
H40.1321 Pigmentary glaucoma, left eye, mild stage
H40.1322 Pigmentary glaucoma, left eye, moderate stage
H40.1323 Pigmentary glaucoma, left eye, severe stage
H40.1324 Pigmentary glaucoma, left eye, indeterminate stage
H40.1331 Pigmentary glaucoma, bilateral, mild stage
H40.1332 Pigmentary glaucoma, bilateral, moderate stage
H40.1333 Pigmentary glaucoma, bilateral, severe stage
H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage
H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage
H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage
H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Any ICD-10-CM code not listed in Group 1 "ICD-10 Codes that Support Medical Necessity" section

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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