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Find out if traditional or MIGS surgeries are more common.

In the first part of this two-article series, Revenue Cycle Insider broke down glaucoma and explored common therapies to alleviate the symptoms. This month, we鈥檒l explain how to report minimally invasive glaucoma surgery (MIGS) and traditional surgeries, so you鈥檙e ready when an operative report enters your workflow.

Before reading part 2, check out part 1 of the series.

Master MIGS Coding

When medications and laser treatment don鈥檛 achieve the desired reduction in intraocular pressure (IOP), surgical intervention may become necessary. MIGS procedures have evolved in the past few decades and offer less trauma to surrounding corneal tissues, lowered risk of scarring, fewer complications, and quicker recovery. Different techniques, tools, and implants offer a variety of options to best address the condition. These procedures involve micro-incisions, specialized tools, and/or miniscule drainage implants, all of which result in faster healing and better patient comfort, for better outcomes with less risk of ocular complications.

Patients with mild or moderate primary open-angle glaucoma (POAG) are the best candidates; some payers have policies to only cover MIGS procedures for mild or moderate POAG.

In 65820 (Goniotomy), the trabecular meshwork is incised for at least 90 degrees (or three clock hours) using a blade or other specialized instrument to open the Schlemm鈥檚 canal. This allows for better drainage of aqueous humor to reduce IOP. Note that National Correct Coding Initiative (NCCI) edits bundle goniotomy with some other MIGS procedures, as the incision made for those surgeries is incidental to the goniotomy incision.

Canaloplasty, coded as 66174 (Transluminal dilation of aqueous outflow canal (e.g. canaloplasty); without retention of device or stent) or 66175 (鈥� with retention of device or stent), involves creating a micro-incision in the sclera, inserting a lighted microcatheter into the Schlemm鈥檚 canal, and advancing it the full length of the canal. As the device is retracted, viscoelastic (a gel-like substance) is injected to maintain or reform the canal to its normal position and shape, thereby opening it for easier outflow of aqueous humor. In 66175, a stent or suture may be placed to aid in the opening of in the canal. 

Solve Stent and Shunt Coding Questions

Physicians permanently insert stents and shunts into the eye to create a drainage bypass. Stents (sometimes called 鈥渁queous drainage devices鈥�) are tube-like devices implanted in the trabecular meshwork for fluid movement through an area that is not draining efficiently. While placement of a stent can be done independently, stents are most often inserted concurrently with the extraction of a cataract.

For standard cataract surgery with a stent implant, assign 66991 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg,irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg,trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more). For stent insertion along with complex cataract surgery requiring additional measures, assign 66989 (... complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more).

Placement of a stent independently of cataract surgery is currently represented by HCPCS Level II code 0671T (Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more). Up to three stents can be placed in one eye at a time for maximum efficiency.

Shunts, sometimes called 鈥済laucoma drainage implants,鈥� redirect fluid through a tube from the anterior chamber to an external reservoir, or plate, situated on the sclera, usually under the eyelid. Fluid collected on the reservoir ultimately distributes naturally into the blood vessels on the surface of the eye. After implantation, a graft of scleral or donor tissue may be placed over the plate to maintain stability and positioning.

For shunts placed without a graft, look to 66179 (Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft). Use of a graft will be indicated with 66180 (Aqueous shunt ...external approach; with graft).

You鈥檒l assign 66183 (Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach) to report a different type of shunt that drains directly out of the eye instead of onto an external reservoir.

Don鈥檛 Forget About Traditional Glaucoma Surgery Options

While employed less frequently than when they were introduced, traditional glaucoma surgical procedures aren鈥檛 without merit and still find their place in the glaucoma lineup.

Code 66170 (Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery) involves removing a piece of the trabecular meshwork in patients who haven鈥檛 had a previous glaucoma surgery. This creates a natural opening through which fluid can drain without placement of a device. Prior to the recent introduction of stents and shunts, this surgery saw higher utilization as a preferred treatment of high IOP.

The evolution of less invasive procedures has reduced the frequency of traditional trabeculectomy, but the procedure remains an option for patients who haven鈥檛 had a prior glaucoma surgery. Report 66172 (鈥� trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents)) for the same approach to remove scar tissue from a previous surgery.

With the rapid advancement of medications and minimally invasive glaucoma surgeries combined with more traditional approaches, physicians have a myriad of options available to treat glaucoma. While the disease remains without a cure, the management options continue to evolve, allowing for a choice unique to each patient鈥檚 disease. 

Christine Killeen, CPC, CPB, COPC, Contributing Writer