New codes and bundles affect your choices more than ever.

You may be aware of two new Category I CPT codes and one new Category III code for use in 2022 with certain glaucoma devices. This area of “minimally invasive glaucoma surgery” has spawned the widespread use of the abbreviation MIGS. Many types of glaucoma surgery fit in here — goniotomy, endocyclophotocoagulation, certain stents and devices, and canaloplasty are but a few of the many choices for surgeons. What you may not be aware of is how to code and file claims when more than one MIGS is done at a single surgical session.

New MIGS codes

Let’s start with the new MIGS codes. Two of them are “combination codes,” meaning they now group together a couple of surgery types (cataract/IOL and MIGS) into a single code. The three new codes are:

• 66989: Extracapsular cataract removal w/IOL insertion, complex; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
• 66991: Extracapsular cataract removal w/IOL insertion; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
• 0671T: Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without extraocular reservoir, and without concomitant cataract removal, one or more

The old codes, 0191T and 0376T, are deleted and cannot be used at all for 2022 dates of service.

There are other interesting subtleties to this new set. The first is the phrase “one or more” at the end of each of the code descriptors. This means there is no longer the ability to report a second or third device. They are all part of the one code, and you report it only once.

The other issue relates to the new Category III code. Here, two devices (iStent [Glaukos] and Hydrus [Alcon]) fit the 0671T code. They are only FDA-approved when they are done with concurrent cataract surgery on the same eye. Neither device implantation — when done as a stand-alone surgery (no cataract surgery on that eye at the same session) — would be an “on-label” use, so they would be a patient-pay service.

Combination codes

Another issue deals with the coding bundle issues that are present with these two Category I CPT combination codes. You may recall the new combination cataract codes added a couple years ago; they were for cataract/IOL done on the same day as endocyclophotocoagulation (ECP); (codes 66987 and 66988). The code descriptor for ECP was modified to add new language to 66711 to make it only when the ECP is not done in the same eye/same day as the cataract surgery. We have two codes because one of the codes in the pair is for “complex cataract/IOL.” Our new combination codes are similar — one for each of the cataract/IOL surgery code options.

The following pairs of cataract combination codes are mutually exclusive with one another for 2022 Q1, so you cannot bill both combination codes:

    * 66987-66989

    * 66987-66991

    * 66988-66989

    * 66988-66991

    * 66989-66991

When choosing a code, choose the higher paying one. Importantly, the patient cannot be billed for the other device/laser if there is any coverage. An ABN or other financial waiver can’t be used to do that either — even if the patient acknowledged it; payers would regard that as inappropriately shifting responsibility to their beneficiary inappropriately for covered services.

Some surgeons might have felt the need to lower the IOP more than cataract surgery alone can do, so they consider many options when deciding what is best for the patient. Not all surgeons like the same MIGS, but thankfully they have many choices. One option here is sometimes referred to as “ICE,” which is short for iStent/Cataract with IOL/ECP (although it could be Hydrus/Cataract as well.) This latest set of combination cataract surgery bundles pretty much kills any chance of billing and being paid for all three codes in the “ICE” combination procedure.

The January 2022 NCCI edits for Q1 seem to allow unbundling in certain situations, because there is a superscript “1” in each direction of the edits. But, importantly, you could only bill that way if the two combination procedures are done on different eyes on the same day. Therefore, it is possible a surgeon or facility might bill 66987 on the right eye and 66989 on the left eye on the same day, but I cannot imagine that surgeons would be doing that very often — they already don’t often do cataract/IOL in two eyes on the same day.

Other longstanding bundling subtleties are now affected in a different way, since the Medicare payments in 2022 are decreased for some surgeries more than others.

One of those examples is the combination of canaloplasty and goniotomy. We have had a longstanding instruction that canaloplasty surgery is the correct code to bill in this instance — and although offices may have grumbled that they couldn’t bill both here if the same eye/same day, it was the higher paying one (canaloplasty) that matched the coding instructions. Now that canaloplasty is the lower-paying code, the surgeon and facility cannot go against this advice and “switch gears” — unless the CPT instructions change down the road.

Fortunately, surgeons have many MIGS options for their glaucoma patients. Don’t be surprised if they change — as long as the recommendations they make still meet medical necessity for an individual patient and also meet coverage guidelines for the other surgery.

Summary

New codes and bundles have greatly changed what MIGS codes surgeons might elect and bill for in 2022. Old codes have been deleted and/or modified and can no longer be used. In some cases, the ability to bill for certain combinations of codes is severely constrained. Since providers have many options in their surgical “toolboxes,” they may choose a different tool than they did in the past.

Lastly, please stay safe. And, as always, “good coding to you.” OP