LCD Reference Article Billing and Coding Article

Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

A56647

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09101 - MAC A	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09201 - MAC A	J - N	Puerto Rico Virgin Islands
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

Article Information

General Information

Article ID
A56647

Article Title
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

Article Type
Billing and Coding

Original Effective Date
12/30/2019

Revision Effective Date
10/07/2023

Revision Ending Date
N/A

Retirement Date
N/A

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38233, Micro-Invasive Glaucoma Surgery (MIGS). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Utilization Parameters

Medicare may cover only 1 unit per eye, per date of service of CPT code 66989 or 66991 for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent^®, or iStent inject^®), performed in conjunction with cataract surgery and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, may be performed using an insertion tool loaded with more than one device, (e.g., iStent inject^®) once the insertion tool is deployed within the eye, the work and clinical skill required to place additional device(s) is equivalent to placement of other U.S. Food and Drug Administration (FDA) cleared devices, described by the same codes. Therefore, only one unit of 66989 or 66991 per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date of service.

Medicare may cover only 1 unit per eye, per date of service of CPT code 0449T for insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45^®), when the medically reasonable and necessary criteria as stated in the LCD are met.

Note: CPT Code 0450T for additional device insertion is not covered.

Note: CPT code 0671T does not need to be reported with any of the following codes: 66982, 66983, 66984, 66987, and 66988.

Documentation Requirements

All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(9 Codes)

Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 66989, 66991 and 0671T.

Group 1 Codes

Code	Description
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage
H40.1121	Primary open-angle glaucoma, left eye, mild stage
H40.1122	Primary open-angle glaucoma, left eye, moderate stage
H40.1123	Primary open-angle glaucoma, left eye, severe stage
H40.1131	Primary open-angle glaucoma, bilateral, mild stage
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage
H40.1133	Primary open-angle glaucoma, bilateral, severe stage

Group 2

(48 Codes)

Group 2 Paragraph

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 0449T (XEN).

Group 2 Codes

Code	Description
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage
H40.1114	Primary open-angle glaucoma, right eye, indeterminate stage
H40.1121	Primary open-angle glaucoma, left eye, mild stage
H40.1122	Primary open-angle glaucoma, left eye, moderate stage
H40.1123	Primary open-angle glaucoma, left eye, severe stage
H40.1124	Primary open-angle glaucoma, left eye, indeterminate stage
H40.1131	Primary open-angle glaucoma, bilateral, mild stage
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage
H40.1133	Primary open-angle glaucoma, bilateral, severe stage
H40.1134	Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1211	Low-tension glaucoma, right eye, mild stage
H40.1212	Low-tension glaucoma, right eye, moderate stage
H40.1213	Low-tension glaucoma, right eye, severe stage
H40.1214	Low-tension glaucoma, right eye, indeterminate stage
H40.1221	Low-tension glaucoma, left eye, mild stage
H40.1222	Low-tension glaucoma, left eye, moderate stage
H40.1223	Low-tension glaucoma, left eye, severe stage
H40.1224	Low-tension glaucoma, left eye, indeterminate stage
H40.1231	Low-tension glaucoma, bilateral, mild stage
H40.1232	Low-tension glaucoma, bilateral, moderate stage
H40.1233	Low-tension glaucoma, bilateral, severe stage
H40.1234	Low-tension glaucoma, bilateral, indeterminate stage
H40.1311	Pigmentary glaucoma, right eye, mild stage
H40.1312	Pigmentary glaucoma, right eye, moderate stage
H40.1313	Pigmentary glaucoma, right eye, severe stage
H40.1314	Pigmentary glaucoma, right eye, indeterminate stage
H40.1321	Pigmentary glaucoma, left eye, mild stage
H40.1322	Pigmentary glaucoma, left eye, moderate stage
H40.1323	Pigmentary glaucoma, left eye, severe stage
H40.1324	Pigmentary glaucoma, left eye, indeterminate stage
H40.1331	Pigmentary glaucoma, bilateral, mild stage
H40.1332	Pigmentary glaucoma, bilateral, moderate stage
H40.1333	Pigmentary glaucoma, bilateral, severe stage
H40.1334	Pigmentary glaucoma, bilateral, indeterminate stage
H40.1411	Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412	Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1413	Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage
H40.1414	Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1421	Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422	Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1423	Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage
H40.1424	Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1431	Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432	Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
H40.1433	Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
H40.1434	Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)

Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes

Code	Description
XX000	Not Applicable

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code	Description
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Other Coding Information

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
10/07/2023	R5	Article revised and published on 11/16/2023 effective for dates of service on and after 10/07/2023 in response to inquiries. The following ICD-10-CM codes have been added to the article: H40.1113, H40.1123, and H40.1133 (Group 1 Codes).
08/02/2022	R4	Article revised and published on 07/20/2023 effective for dates of service on and after 08/02/2022 because the device represented by CPT code 0671T received FDA clearance on 08/02/2022. The following CPT code has been added to the CPT/HCPCS Group 1 Codes and the ICD-10-CM Codes that Support Medical Necessity Group 1 Paragraph sections: 0671T. The following CPT code has been removed from the CPT/HCPCS Group 3 Codes considered not medically reasonable and necessary (non-covered) section: 0671T. The following was added to the Coding Guidance section: Note: CPT code 0671T does not need to be reported with any of the following codes: 66982, 66983, 66984, 66987, and 66988.
01/01/2022	R3	Article revised and published on 01/20/2022 effective for dates of service on and after 01/01/2022 to reflect the Annual CPT/HCPCS Code Updates. The following CPT codes have been added to the Article: 66989, 66991 were added to the CPT/HCPCS Group 1 Codes and the ICD-10-CM Codes that Support Medical Necessity Group 1 Paragraph sections. 0671T was added to the CPT/HCPCS Group 3 Codes considered not reasonable and necessary. The following CPT codes have been deleted and therefore have been removed from the article: 0376T from the CPT/HCPCS Group 3 Codes and 0191T from the CPT/HCPCS Group 1 Codes, the ICD-10-CM Codes that Support Medical Necessity Group 1 Paragraph and the Frequency Limitations sections. Also, the Frequency Limitations section is now titled Utilization Parameters with the addition of clarifying language for CPT codes 66989 and 66991. Minor formatting changes have been made throughout the Article.
04/27/2020	R2	Revision Number: 1 Publication: May 2020 Connection LCR A/B2020-031 Explanation of Revision: Based on further review, the “Coding Guidelines” section of the Billing and Coding article was revised to add CPT codes 66987 and 66988. The effective date of this Billing and Coding article revision is for claims processed on or after 04/27/2020, for dates of service on or after 01/01/2020.
12/30/2019	R1	The content in the Billing and Coding Article was revised to be consistent with the new format supported by CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1.

Associated Documents

Updated On	Effective Dates	Status
11/09/2023	10/07/2023 - N/A	Currently in Effect	You are here
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Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

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CMS National Coverage Policy

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Response To Comments

Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 2

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

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Revenue Codes

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Other Coding Information

Group 1

Coding Table Information

Revision History Information

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