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April 1, 2020 NCCI Bundling Edits Affecting Ophthalmology

CMS’ National Correct Coding Initiative (NCCI) Edits, version 26.1, effective April 1, 2020, include new edits that impact some glaucoma surgery billing.  Under the new edits, CPT 65820 (Goniotomy) is bundled with all of the following procedures:

66150   Fistulization of sclera for glaucoma; trephination with iridectomy

66155   Fistulization of sclera for glaucoma; thermocauterization with iridectomy

66160   Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy

66170   Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery

66172   Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (including injection of antifibrotic agents)

66175   Transluminal dilation of aqueous outflow canal; with retention of device or stent

66184   Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft

66185   Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

66710   Ciliary body destruction; cyclophotocoagulation, transcleral

66762   Iridoplasty by photocoagulation

The Bundling Edit or Indicator Status for each of these code combinations is “1”, which allows for the codes to be ‘unbundled’ and reimbursed separately when appropriate.  To communicate your intent to ‘unbundle’ codes that are otherwise bundled under NCCI edits, append modifier 59 or a suitable X-modifier.  Rationale to support this claim must be evident in the chart. The NCCI instructions contain a Modifier 59 Article (click here) that outlines the appropriate use of this modifier.  In 2015, to help clarify when unbundling was appropriate, CMS introduced the X-modifiers, as a subset to modifier 59.   These modifiers are explained in the Modifier 59 Article, as well, beginning on page 4 of the document.  Our FAQ, Reimbursement Issues Related to Modifier 59, includes instructions on when the modifiers are appropriate.

It is interesting that the April 1 edits do not preclude billing goniotomy with CPT 66174 (Transluminal dilation of aqueous outflow canal; without retention of device or stent).  This combination of codes has been questioned in the past.  Instruction was provided by CPT Assistant in their September, 2019 publication; the entry instructs billers not to report these codes together even absent an NCCI edit to that affect.  The American Academy of Ophthalmology has given the same advice. 

A complete list of the version 26.1 edits can be found on the CMS website (link here) and in the Corcoran Medicare Quick Reference Guide available on our website or mobile app.

As always, we are happy to assist you with claims issues and other topics related to eye care during this public health emergency.  Check back often for updated News Items related to billing, documentation, and operations related to your practices during COVID-19.  Stay safe.

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