Endoscopic cyclophotocoagulation (ECP) is a cyclodestructive procedure developed by Martin Uram, MD, in 1990 and cleared by the FDA in 1991.¹ It uses a probe with 3 elements: (1) an image guide, (2) a light source, and (3) a laser.² The surgeon has direct visualization of the ciliary processes, and this enables precise delivery of laser energy and limits damage to the underlying ciliary body and neighboring tissue. Endoscopic cyclophotocoagulation minimizes the disadvantages of trans-scleral cyclodestructive procedures while maximizing the advantage of ablating the ciliary body epithelium to decrease intraocular pressure. Endoscopic cyclophotocoagulation is indicated for the treatment of glaucoma in patients who have failed conventional topical and systemic medications, previous laser photocoagulation, trabeculectomy and other filtering procedures, cyclocryotherapy, or other cyclodestructive procedures.³

Utilization

Since 2006, ECP has been used for Medicare beneficiaries at a modest rate compared to other glaucoma procedures, as shown in Figure 1. More recently, as other minimally invasive glaucoma surgery techniques have become more popular, ECP has declined a little.

CPT Coding Change

In 2005, the CPT manual added ciliary body destruction by cyclophotocoagulation; 66710 described a trans-scleral approach, and 66711 described an endoscopic approach (ECP). In 2017, the Centers for Medicare & Medicaid Services (CMS) determined that ECP was reported on the same claim with cataract surgery 75% of the time or more.⁴ Prompted by this information, in 2018, the AMA’s CPT Editorial Panel considered a Code Change Request and decided to add 2 new codes in the 2020 CPT manual. The first is 66987, which is defined as extracapsular cataract removal with insertion of intraocular lens prosthesis (a 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 performed on patients in the amblyogenic developmental stage, with endoscopic cyclophotocoagulation. The second is 66988, which is defined as extracapsular cataract removal with insertion of intraocular lens prosthesis (a 1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), with endoscopic cyclophotocoagulation. While CPT 66710 remains unchanged, 66711 was revised so it will no longer be used when ECP is performed at the same time as cataract surgery: “Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens.”

Coverage Limitations

Currently, there exist no national or local coverage Medicare policies pertaining to cyclophotocoagulation. Unlike temporary category III codes, claims for reimbursement are not typically a problem for ECP.

Reimbursement

Starting January 1, 2020, for 66711, the national Medicare payment rate to a surgeon declined by 22% from $659 in calendar year 2019 to $514.⁴ Facility reimbursement for 66711 increased by 4% for ambulatory surgery centers and 5% for hospital outpatient departments in 2020.^5,6

CMS assigned no relative value units to 66987 and 66988, but rather it requires Medicare Administrative Contractors (MACs) to determine the payments to surgeons.⁴ The effect of this decision is to inject some uncertainty and variability into physician reimbursement.

Medicare reimbursement for the new CPT codes rose dramatically in 2020 compared to the prior regime of billing for 66711 with 66982 or 66984. In ambulatory surgery centers, payments for 66987 and 66988 each are set at $2,393, a 63% increase compared to 2019. For hospital outpatient departments, the payments for 66987 and 66988 each are set at $3,818, a 99% increase, primarily due to the effect of the comprehensive ambulatory payment classification.^5,6 Table 1 describes these changes.

National Correct Coding Initiative Edits

According to the October 1, 2019 National Correct Coding Initiative (NCCI) edits, 66711 is bundled with a large number of noncataract procedures. The sidebar “NCCI 66711 Bundles” lists some of the noteworthy exclusions.

Problematic Charting

In most cases, chart documentation for ECP is straightforward, but our experience with chart reviews has identified problems in some instances that can readily be avoided with a little care. The operative report for concurrent cataract surgery with ECP sometimes suffers from incompleteness due to the use of a uniform and repetitive chart note for the cataract surgery that omits mention of the glaucoma procedure. This may occur when a template is used for the operative report rather than a unique dictation. The billers for the surgeon and the facility, when presented with a chart that only describes cataract surgery, will not bill for the ECP. An error of this type can be prevented with some attention to the surgery schedule, the presenting conditions, and a double check of the documentation prior to signing it.

Conclusion

Starting January 1, 2020, CPT 66711 should not be reported in conjunction with cataract surgery. Ophthalmologists must use new CPT codes 66987 and 66988 for all combined ECP and cataract surgical services. Growth in ECP utilization, particularly with concurrent cataract surgery, contributed to the recent 22% decrease in physician payment for 66711. Physician reimbursement for 66987 and 66988 is determined by the individual MAC. While facility reimbursement increased slightly for 66711 in CY 2020, there are dramatically increased Medicare payments for 66987 and 66988 compared to previously billing 66711 with 66982 and 66984. It is likely that additional instructions from Medicare and other third-party payers pertaining to these new codes will be forthcoming in 2020. GP

References

1. The US Food and Drug Administration. 510(k) clearance Uram Ophthalmic Laser Endoscope. K910532 05/28/1991
2. Seigel MJ. Endoscopic cyclophotocoagulation (ECP). Available at: https://eyewiki.aao.org/Endoscopic_Cyclophotocoagulation_(ECP) . Accessed December 2, 2019.
3. The US Food and Drug Administration. Special 510(k) Summary for Microprobe Laser and Endoscopy System. K042918. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf4/K042918.pdf . Accessed December 2, 2019.
4. CMS-1715-F and IFC. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule. 84 FR 62568. Published November 15, 2019. PFS Final Rule Addendum B – Relative Value Units and Related Information Used in CY 2020 Final Rule. Available at: 2020 https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other . Accessed December 2, 2019.
5. CMS-1717-FC. Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children’s Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity To Apply for Available Slots. 84 FR 61142. Published November 12, 2019. ASC Addendum AA-- Final ASC Covered Surgical Procedures for CY 2020. Available at: https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/Downloads/CMS-1717-FC-ASC-Addenda-AA-BB-DD1-DD2-EE.zip . Accessed December 2, 2019.
6. 2020 NFRM Addendum B.-Final OPPS Payment by HCPCS Code for CY 2020. Available at: https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1717-FC-2020-OPPS-Addenda.zip . Accessed December 2, 2019.

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California.