IACCESS™ Trabecular Trephine – How to Code?

Summary:   Glaukos’ new product, the IACCESS™ trabecular trephine, raises interesting coding questions.  Standalone procedures should be reported on a claim for reimbursement as unlisted procedure, anterior segment of eye (66999).

A YouTube video by Joseph T. Kavanaugh, MD introduced viewers to an innovative instrument designed by Mark Gallardo, MD of El Paso, Texas – the Glaukos IACCESS™ trabecular trephine.  A trephine is an instrument with a cylindrical blade used in surgery to remove a circle of tissue or bone.  The IACCESS™ instrument is used to make small (220 µm) holes in trabecular meshwork (TM) to a depth of 300 µm.  Dr. Kavanaugh describes this as a “much smaller goniotomy”.  However, what Dr. Kavanaugh is describing is more correctly termed a “trabeculostomy” (i.e., a round surgical opening in the TM to connect the anterior chamber to Schlemm’s canal to allow aqueous to pass and exit the eye through the collector channels).  The term trabeculostomy is used in the scientific literature,[1] and has been the subject of a thorough review of experience over decades.[2]

Incisional goniotomy, as originally described by Barkan[3] and Swan,[4] involves creation of a goniotomy cleft in “…one-quarter to one-third of the circumference of the angle [that] is treated…”.[5]  It is fair to say that there is a substantial difference between a long incision and a small puncture(s) in TM, and that goniotomy (CPT 65820) is not accurate to describe the use of the Glaukos IACCESS™ trabecular trephine.  The information provided by Glaukos in their billing and coding guide is problematic because it translates Dr. Kavanaugh’s description into a suggestion for filing claims for reimbursement.

In CPT, trabeculostomy is used in 0621T and 0622T but only when it is created with an excimer laser.  A related word with the same suffix was used by Robert Stegmann, MD in a 1999 seminal publication – viscocanalostomy.[6]  CPT instructs, “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”  In this case, use 66999 (Unlisted procedure, anterior segment of eye).

Why the affinity for the term goniotomy to describe a procedure performed with this new instrument?  At the present time, CPT 65820 enjoys favorable Medicare reimbursement for a surgeon and a facility.  Recent Medicare payment rate changes for other MIGS procedures has lowered reimbursement.  Enthusiasm for alternative procedures, such as goniotomy, is easy to appreciate, however improper use is not.

[1]  Berlin M, Töteberg-Harms M, Roka V, Kleineberg L, Stodtmeister R, Giers U, et al. 27th American Glaucoma Society Meeting. 2017. Excimer Laser Trabeculostomy (ELT), a Laser Based MIGS Procedure with No Implants, Enables Consistent Intraocular Pressure-Lowering in Glaucoma Patients Over 8 Years, Both Stand-Alone and Combined With Phacoemulsification.

[2]  Durr, GM, et al  Current Review of Excimer Laser Trabeculostomy  Eye Vis (Lond) 2020; 7:24  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199329/

[3]  Barkan, O, Technic of Goniotomy  Arch Ophthalmol 1938;19(2):217-223   https://jamanetwork.com/journals/jamaophthalmology/article-abstract/613422

[4]  Swan, KC, Goniotomy-a Modified Lens and Technique  Arch Ophthalmol 1965;74(2):231-234   https://jamanetwork.com/journals/jamaophthalmology/article-abstract/628088

[5]  Lister, A Technique of Goniotomy  Brit J Ophthal (1965) 49, 594   https://bjo.bmj.com/content/bjophthalmol/49/11/594.full.pdf

[6]  Stegmann, R, Pienaar, A, Miller, D, Viscocanalostomy for open-angle glaucoma in black African patients.  J Cataract Refract Surg. 1999 Mar;25(3):316-22  https://pubmed.ncbi.nlm.nih.gov/10079435/

We are available and happy to assist you with issues such as this and other topics related to eye care.  We’re proud to assist with questions related to 2021 changes on Evaluation and Management eye exam coding, the increased activity from payers (e.g., Private payers, and the CMS TPE, RAC, and SMRC reviews) so contact us if you need our help with these responses.  Stay safe in this challenging time.

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