Streamline® Viscoelastic Injector – How to Code?

Summary:   New World Medical’s new product, the Streamline® Viscoelastic Injector, raises interesting coding questions.  Standalone procedures with it should be reported on a claim for reimbursement as  unlisted procedure, anterior segment of eye (66999).  When injection of viscoelastic is incidental to another glaucoma procedure, it should not be reported at all.

Streamline® Viscoelastic Injector by New World Medical, Inc. is a single-use disposable cannula for use during ophthalmic surgical procedures to deliver small amounts of viscoelastic fluid.[1]  In a recent YouTube video by Malik Kahook, MD, he demonstrates how this instrument is used to inject a viscoelastic agent into Schlemm’s canal (SC).  The company’s website contains an educational video to describe the Streamline® Surgical System: the instrument, its design, and its functionality.  Glaucoma surgeons are not strangers to the use of viscoelastic in the eye as occurs with reversing hypotony.[2]  CPT 66020 (Injection, anterior chamber of eye [separate procedure]; air or liquid) is used to report that, however the Streamline® Viscoelastic Injector puts the viscoelastic behind the trabecular meshwork (TM) in SC and not in the anterior chamber (AC).  While there are many CPT code descriptors that contain the word “injection”, none fit this procedural description.  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).  This topic was briefly touch upon in an article in EyeNet Magazine, a publication of the American Academy of Ophthalmology, that stated, “If you inject viscoelastic into a limited portion of the canal via an opening created through the trabecular meshwork, don’t use 66174.  Use 66999Unlisted procedure, anterior segment of eye.”[3]   CPT 66174 describes “Transluminal dilation of aqueous outflow canal; without retention of device or stent”.

In both videos, “goniotomy” is mentioned as a description of this procedure which deserves consideration.  Incisional goniotomy as originally described by Barkan[4] and Swan,[5] involves creation of a goniotomy cleft in “…one-quarter to one-third of the circumference of the angle [that] is treated…”.[6]  A number of instruments can be used to create a goniotomy cleft including one made by New World Medical, the Kahook Dual Blade.[7i]  It is fair to say that there is a substantial difference between an injection and a lengthy incision in TM, and that goniotomy (CPT 65820) is not accurate to describe the use of the Streamline® Viscoelastic Injector.

As a further consideration, the injection of viscoelastic into SC may be incidental to another minimally invasive glaucoma surgery such as implantation of a Hydrus® Microstent.  Then, a separate CPT code is not needed for the injection because it is part of a larger service and not distinct from it.

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 alternatives, such as goniotomy, is easy to appreciate, however improper use is not.

[1]  DHHS FDA 510(k) K211680

[2]  Chiam, PJ, Chen, X, Haque, MS, Sung, VC, Outcome of fixed volume intracameral sodium hyaluronate 1.4% injection for early postoperative hypotony after Baerveldt glaucoma implant  Clin Exp Ophthalmol 2018 Dec;46(9): 1035-1040

[3] AAO Eyenet Magazine. Savvy Coder. March 2022, p. 73.

[4]  Barkan, O, Technic of Goniotomy  Arch Ophthalmol 1938;19(2):217-223

[5]  Swan, KC, Goniotomy-a Modified Lens and Technique  Arch Ophthalmol 1965;74(2):231-234

[6]  Lister, A  Technique of Goniotomy  Brit J Ophthal (1965) 49, 594

[7i]  AAO EyeWiki  Kahook Dual Blade: Ab Interno Trabeculectomy

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