Among the available surgical options for the treatment of glaucoma, the fastest growing segment is minimally invasive glaucoma surgery (MIGS), and particularly implantation of an aqueous drainage device by an internal approach (Figure 1). Recognizing the widespread adoption of 0191T (insertion of anterior segment aqueous drainage device without extraocular reservoir, internal approach into the trabecular meshwork) during the prior 10 years, CMS advised AMA’s CPT Editorial Panel in 2019 that the temporary, new technology, Category III CPT code created in 2009 was no longer appropriate and that a permanent, Category I CPT code was needed. In 2020, AMA’s CPT Editorial Panel examined this issue and recommended deletion of 0191T, as well as +0376T (for the second implant), and replacement with 2 new combination codes:
- 669X1 - Complex cataract surgery with IOL and implantation of an aqueous drainage device
- 669X2 - Routine cataract surgery with IOL and implantation of an aqueous drainage device
This coincides with the FDA-approved directions for use of the 2 relevant products, iStent (Glaukos) and Hydrus (Ivantis), “…for use in conjunction with cataract surgery for the reduction of intraocular pressure (IOP) in adult patients with mild or moderate open-angle glaucoma.” For a complete description of the indications and contraindications, refer to the manufacturers’ package inserts with full instructions.
In 2021, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveyed a sample of ophthalmologists about the duration and complexity of these procedures and made recommendations to CMS about the relative value units (RVU) for them. These RUC recommendations were considered, and finally accepted, in the long process leading to the 2022 Medicare Physician Fee Schedule implemented on January 1. Also, on January 1, the new Category I CPT codes were inaugurated:
- 66989 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), 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 preformed 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.
- 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.
During this time, the 2 manufacturers directly associated with these MIGS procedures, Glaukos and Ivantis, continued their research and development efforts to address the needs of other open-angle glaucoma patients who did not require concurrent cataract surgery, particularly pseudophakic patients. In 2020, while deliberations about 0191T were under way, a new Category III code was requested and ultimately approved:
- 0671T – Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without extraocular reservoir, and without concomitant cataract removal, one or more
The clinical trials, currently under way, to garner FDA approval for standalone indications for Hydrus and iStent support the need for this new Category III code. Although 0671T was also added to the CPT manual on January 1, 2022, there are not yet any approved products for it; however, they are anticipated soon. At present, this is an experimental and investigational procedure, so any claims would not be reimbursed.
During the time that 0191T was used on claims for reimbursement, CMS established Medicare payment rates in the Outpatient Prospective Payment System (OPPS) for ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs); however, the Medicare payments to physicians were determined by the Medicare Administrative Contractors (MACs). Consequently, there was significant variation in the surgeon’s reimbursement for 0191T throughout the country. Table 1 summarizes the national payment rates in 2021 and 2022 for all glaucoma procedures, including these MIGS procedures, and the percentage change in reimbursement where it is known. Throughout 2021, there was trepidation about anticipated Medicare cuts to physicians and other providers, but in December, 2021, Congress passed the Protecting Medicare and American Farmers from Sequester Cuts Act, which mitigated those fears, as shown in Table 1.
Description | CPT | 2021 MD | 2022 MD | 2021 ASC | 2022 ASC | 2021 HOPD | 2022 HOPD | MD | ASC | HOPD |
Goniotomy | 65820 | $825 | $838 | $1,872 | $1,919 | $3,918 | $4,000 | 2% | 2% | 2% |
Trabeculotomy | 65850 | $851 | $848 | $1,039 | $1,063 | $2,079 | $2,121 | 0% | 2% | 2% |
Laser trabeculoplasty | 65855 | $207 | $206 | $138 | $133 | $504 | $514 | -1% | -4% | 2% |
Trabeculectomy | 66170 | $1,102 | $1,096 | $1,039 | $1,063 | $2,079 | $2,121 | -1% | 2% | 2% |
Trabeculectomy, scar | 66172 | $1,203 | $1,197 | $1,039 | $1,063 | $2,079 | $2,121 | -1% | 2% | 2% |
Canaloplasty | 66174 | $948 | $761 | $1,872 | $1,919 | $3,918 | $4,000 | -20% | 2% | 2% |
Canaloplasty, stent | 66175 | $994 | $799 | $1,872 | $1,919 | $3,918 | $4,000 | -20% | 2% | 2% |
Tube shunt | 66179 | $1,088 | $1,083 | $1,872 | $2,491 | $3,918 | $4,000 | 0% | 33% | 2% |
Tube shunt, graft | 66180 | $1,148 | $1,142 | $2,524 | $2,582 | $3,918 | $4,000 | -1% | 2% | 2% |
ExPRESS | 66183 | $1,038 | $1,032 | $2,726 | $2,787 | $3,918 | $4,000 | -1% | 2% | 2% |
Revise tube shunt | 66184 | $796 | $1,032 | $1,039 | $1,063 | $2,079 | $2,121 | 30% | 2% | 2% |
Revise tube shunt, graft | 66185 | $856 | $794 | $1,039 | $1,063 | $2,079 | $2,121 | -7% | 2% | 2% |
TSCPC | 66710 | $394 | $392 | $854 | $874 | $2,002 | $2,044 | 0% | 2% | 2% |
ECP | 66711 | $510 | $507 | $1,039 | $1,063 | $2,079 | $2,121 | -1% | 2% | 2% |
Laser PI | 66761 | $238 | $237 | $194 | $186 | $504 | $514 | 0% | -4% | 2% |
Iridoplasty | 66762 | $428 | $425 | $255 | $261 | $504 | $514 | -1% | 2% | 2% |
Complex cataract | 66982 | $751 | $746 | $1,039 | $1,063 | $2,079 | $2,121 | -1% | 2% | 2% |
Routine cataract | 66984 | $548 | $545 | $1,039 | $1,063 | $2,079 | $2,121 | -1% | 2% | 2% |
Complex cataract, ECP | 66987 | Carrier price | Carrier price | $2,441 | $1,919 | $3,918 | $4,000 | -21% | 2% | |
Routine cataract, ECP | 66988 | Carrier price | Carrier price | $2,441 | $1,919 | $3,918 | $4,000 | -21% | 2% | |
Complex cataract, stent* | 66989 | Carrier price | $857 | $3,346 | $3,246 | $3,918 | $4,251 | -3% | 8% | |
Routine cataract, stent* | 66991 | Carrier price | $683 | $3,346 | $3,246 | $3,918 | $4,251 | -3% | 8% | |
Aqueous drainage device | 0191T | Carrier price | Carrier price | $2,826 | $- | $3,918 | $- | |||
ADD, suprachoroid | 0253T | Carrier price | Carrier price | $2,625 | $2,684 | $3,918 | $4,000 | 2% | 2% | |
ADD, subconj | 0449T | Carrier price | Carrier price | $2,910 | $2,974 | $3,918 | $4,000 | 2% | 2% | |
ADD, subconj, 2nd | 0450T | Carrier price | Carrier price | $- | $- | $- | $- | |||
ADD, w/o cataract | 0671T | Carrier price | Carrier price | $- | $1,601 | $- | $2,121 | |||
* 2021 ASC values are a calculation based on cat + MIGS; HOPD values are comprehensive APC. |
In the Medicare Physician Fee Schedule, CMS assigned 90-day global periods to 66989 and 66991; 0671T is not assigned a global period. Significantly, the variation in physician payment for these procedures now depends on published geographic indices rather than individual MAC determinations.
Although new products and innovations are sure to come along in the future, these MIGS procedures are now considered mainstream for glaucoma surgery and not emerging technologies, as evidenced by these coding and reimbursement changes. GP