Glaucoma specialists and general ophthalmologists alike must be aware of some significant procedure coding changes that will increase the complexity of the glaucoma surgical code set.
Take-home message: Glaucoma specialists and general ophthalmologists alike must be aware of some significant procedure coding changes that will increase the complexity of the glaucoma surgical code set.
coding.doc By L. Neal Freeman, MD, MBA, FACS
Current Procedural Terminology (CPT) for 2015, just as in 2014, includes significant modifications for glaucoma surgery reporting. At least some of the changes increase the complexity of the glaucoma surgical code “family.”
The Centers for Medicare and Medicaid Services (CMS) will likely enjoy substantial savings as a result of these changes. The associated impact in overall physician allowables has had notable impact on glaucoma specialists and general ophthalmologists alike.
The increase in complexity is related to expansion of the “aqueous shunt to extraocular plate reservoir” code set. This set was previously comprised of two separate codes describing placement of the aqueous shunt (CPT 66180) and revision of a previously placed shunt (CPT 66185).
CPT code 67255 (scleral reinforcement (separate procedure), with graft) was also a very relevant code in the context of these services. Prior to the 2015 change, it was permissible to report 67255 with either of the two shunt codes when a patch graft was used with the shunt.
However, as part of efforts to limit health-care spending, codes that are frequently reported together are identified for potential modification. Medicare’s idea is to combine frequently combined services into one inclusive code.
This process led to these changes that were implemented in 2015, which disallowed the separate reporting of graft code 67255.
These codes with the associated descriptors are part of CPT 2015:
(CPT 66179 and CPT 66184 are new codes, and CPT 66180 and CPT 66185 are revised codes.)
Reimbursement for the combined service captured in the new code descriptors for 66180 and 66185 is less than reimbursement for the code combinations that included the graft code that were used prior to 2015. This bundling policy has similarly resulted in reduction in physician payment for many services across the medical landscape.
These changes also affect facility payments.
Next: Category III changes
However, Medicare has recently addressed the decline in facility payment associated with the inability to report 67255. Transmittal instructions from April 2015 allow ambulatory surgery centers to report and receive payment at acquisition or invoice cost for the corneal tissue code V2785 when reported with procedures 66180 and 66185.
Other changes in glaucoma procedure coding occurred in category III (new technology codes) of CPT.
The changes include the following:
This addition to the category III codes facilitates reporting of insertion of more than one stent (iStent, Glaukos) or related device.
There is a technical change in the category III code 0253T for stents that channel aqueous into the suprachoroidal space as well. This technical change does not change the wording of the code nor its use, however.
Coverage and payment for category III codes is payer-dependent. However, certain payers may issue guidelines concerning various category III codes.
For example, recent policy statements by both Aetna and Cigna indicate that when criteria are met, coverage is provided for category III codes 0191T and 0376T. The same statements indicate that neither payer will cover 0253T.
Next: Lessons you need to learn from the changes
Although not yet used outside clinical trials, placement of a drug-eluting stent into the canaliculus is another procedure used for control of elevated IOP. Ocular Therapeutix, with its sustained-release plug technology, achieved category III status commencing in 2014 as 0356T, Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each.
Clinicians and billers that rely upon the physical CPT manual (not advance information on the American Medical Association website, http://www.ama-assn.org/ama) will note the first appearance of this code in the 2015 edition. The company website (http://www.ocutx.com/pipeline/travoprost-punctum-plug) indicates that the prostaglandin analogue, travoprost, is the agent currently used with its device for IOP control.
Lessons learned from changes
The effect of the code screens that lead to increased bundling of services is substantial. Bundling will change reporting requirements, but will also be associated with reimbursement changes for physicians and the facilities in which they operate. The financial savings to the Medicare program have yet to be fully understood.
Also, the development of category III codes and the eventual graduation of some of these services into category I CPT status (the familiar five-digit codes occupying most of the CPT manual) must be followed. In some cases, payment for these services is fairly readily obtained. Practices that learned about this process will be rewarded.
Focus upon the coding and reimbursement process and how it develops to achieve maximum, appropriate compensation for surgical efforts.
L. Neal Freeman, MD, MBA, FACS, is president of CPR Analysts Inc. (www.cpranalysts.com.) He advises physicians nationally on coding, reimbursement, and practice management. Dr. Freeman is a practicing ophthalmic plastic surgeon and a certified specialist in physician coding. Readers may contact him at firstname.lastname@example.org or 321/253-2166.
CPT codes, descriptions, and other data only are copyright 2015 by the American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.