Guidance for Coding Goniotomy
Summary: Two new ophthalmic surgical products have attracted interest from surgeons: Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos). In both cases, the company recommends CPT 65820, goniotomy, be reported on claims for reimbursement. A recent publication by the American Academy of Ophthalmology about goniotomy is informative and provides a different viewpoint particularly about the extent of the surgery. Surgeons and facilities should take heed.
An informative Fact Sheet by the American Academy of Ophthalmology (AAO) about billing for goniotomy (65820) was published June 7, 2022. It reiterates some points contained in CPT, CPT Assistant, and the National Correct Coding Initiative (NCCI).
- CPT 65850 is used to report trabeculotomy ab externo while 65820 is used to report trabeculotomy ab interno, also known as goniotomy. The Fact Sheet adds that, “…the trabecular meshwork is opened for at least 3 clock hours.”
- In CPT Assistant, a description of goniotomy states, “After gonioscopy under the microscope with traction sutures in place and with a special gonioprism, the gonioknife is used to enter the cornea, pass across the iris, and slit Barkan’s membrane for the desired area, usually 180 degrees.” 
- In CPT, the parenthetical instruction with 66174 (canaloplasty) says, “Do not report 66174 in conjunction with 65820”. 
- In CPT, the add-on code +69990, Microsurgical techniques, requiring use of an operating microscope, may only be reported with a few procedures; 65820 is one of them.  It is reportable by the surgeon and, like other add-on codes, is not subject to the multiple surgery payment reduction.
- In CPT Assistant, a reader asked about coding for combined canaloplasty (66174) and goniotomy (65820), and was advised, “…Transluminal dilation of aqueous outflow canal; without retention of device or stent, should be reported…The incision inherent in code 65820, goniotomy, does not involve any additional physician work; therefore, code 65820 should not be reported separately in conjunction with 66174.”  An earlier publication on the same topic said, “Only code 66174 should be reported, as this procedure represents the service performed, and the incision inherent in goniotomy is incidental to code 66174.”  The current NCCI edits have the same limitation on this code combination.
The Fact Sheet also restates the May 2018 guidance of Dr. Cynthia Mattox, past president of the American Glaucoma Society (AGS), and Sue Vicchrilli, past Academy Director of Coding and Reimbursement that, “Goniotomy should not be coded in addition to other angle surgeries or canal implants.” Echoing that guidance, Novitas and First Coast Service Options, Medicare Administrative Contractors, published in their Local Coverage Determination, L38223, that, “Goniotomy procedure performed in conjunction with the insertion of a glaucoma drainage device … is considered not medically reasonable and necessary.”  While the CMS National Correct Coding Initiative (NCCI) does not presently contain a bundle for 65820 and 66989 (complex cataract/stent) or 66991 (routine cataract/stent), the Novitas and FCSO LCD and the AAO/AGS guidance are instructive and should not be ignored.
AAO’s Fact Sheet contains specific guidelines related to Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos).
- “If the procedure performed consists of several punctures, injection of a small amount of viscoelastic, or other limited interventions report using unlisted CPT code 66999.”
To highlight the distinction between several punctures or injections and the traditional incisional goniotomy described in CPT Assistant, as well as the scientific literature, the Fact Sheet says, “When multiple incisions are performed opening the trabecular meshwork over an area of at least 90 degrees, report using CPT code 65820, goniotomy.” The April 2022 Streamline Surgical System instructions for use notes that the injection site in the trabecular meshwork “…can be extended to the desired length by directing the exposed cutting cannula across the canal.” With repetition, treatment can be symbolized as —-X—-X—-X—-X—- where the “X” is an injection site and the dashes are extensions of the initial hole, left and right, which collectively create an incisional goniotomy over 90-180 degrees.
While ophthalmologists generally express interest and enthusiasm for new tools and techniques, it takes much more than an injection of viscoelastic or a few small punctures in trabecular meshwork to qualify as goniotomy.
 AAO Fact Sheet: Goniotomy, June 7, 2022 https://www.aao.org/Assets/c1c5ad6a-f611-4c41-988c-991514f68602/637896975656770000/goniotomy-fs-pdf?inline=1
 2022 CPT Professional edition
 CPT Assistant, July 2018
 CPT Assistant, September 2019, page 11
 CPT Assistant, September 2018, page 9
 2022 NCCI edits for 66174 and 65820
 Novitas, LCD L38223 https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38223
 New World Medical, Inc. Streamline® Surgical System Instructions For Use. 50-0145 REV C. 2022-04
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