Reimbursement for Canaloplasty (Ellex)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR CANALOPLASTY
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Q What is canaloplasty?
A Canaloplasty is a microcatheter-based interventional surgery for open-angle glaucoma. There are two surgical approaches: ab externo (from outside) and ab interno (from inside). In both surgeries, a microcatheter navigates Schlemm’s canal 360 degrees to restore normal aqueous outflow. The ab interno approach employs viscoelastic to dilate Schlemm’s canal, while the ab externo approach uses suture to tighten and distend the trabecular meshwork.
Q What are the indications for canaloplasty?
A Canaloplasty is indicated for the reduction of intraocular pressure in adult patients with primary or chronic open angle glaucoma (OAG). Canaloplasty is also used to treat other open angle glaucomas in patients refractory to or intolerant of medications with one or more of the following conditions:
- Primary open angle glaucoma
- Exfoliative glaucoma
- Failed laser trabeculoplasty
- Glaucoma with anatomically open angles when target IOP is documented as failed or unlikely to be achieved with medication alone
Q What are the contraindications for canaloplasty?
A Canaloplasty is contraindicated in the following circumstances:
- Eyes with narrow angle glaucoma
- Eyes with steep peripheral or plateau iris
- Eyes with angle closure glaucoma
- Eyes with angle recession
- Eyes with peripheral anterior synechiae
- Eyes with chronic inflammation or neovascularization
- Eyes with secondary glaucoma following gross trauma
- Prior trabeculectomy, shunt implantation or other procedure which resulted in scarring in the region of Schlemm’s canal that would prevent full 360o catheterization of the canal
- Patients who cannot comply with postoperative instructions (i.e., poor mentation)
- Any ophthalmic surgeon who has not been formally trained to perform canaloplasty or other non-penetrating procedures which access Schlemm’s canal
Q Is the microcatheter approved by the FDA?
A Yes. The microcatheter received 510(k) clearance from the FDA on July 18, 2008 for catheterization and viscodilation of Schlemm’s canal to reduce intraocular pressure in adult patients with open angle glaucoma.
Q What CPT code(s) is used to describe canaloplasty?
A Effective January 1, 2011, there are two CPT codes that describe interventional glaucoma surgery.
66174 Transluminal dilation of aqueous outflow canal; without retention of device or stent
66175 Transluminal dilation of aqueous outflow canal; with retention of device or stent
Ab interno canaloplasty (ABiC™) with iTrack and viscodilation of Schlemm’s canal is best described as 66174. Ab externo canaloplasty with suture is best described as 66175.
Q What is the physician reimbursement for 66174 and 66175?
A In 2019, the Medicare Physician Fee Schedule allowable amounts are $971 for 66174 and $1,017 for 66175. These amounts are modified by local indices, so actual payments will vary. Other payers set their own rates, which may differ significantly from Medicare’s fee schedule.
Q Is transluminal canal dilation bundled with other services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 66174 and 66175 are bundled with some ophthalmic procedures, but not with cataract surgery or other major glaucoma surgeries (e.g., endoscopic cyclophotocoagulation, aqueous drainage device, or goniotomy). However, the American Glaucoma Society and other professional societies recommend billing for only 1 angle procedure at an encounter, even if NCCI edits do not limit the claim.
Q How is the facility reimbursed for these services?
A The 2019 Medicare allowable amounts in an ambulatory surgery center (ASC) and hospital outpatient department (HOPD) are as follows.
These amounts are modified by local wage indices. Other payers have their own payment amounts, which may vary considerably from Medicare.
Q What is the significance of the J1 indicator?
A The application of the multiple procedure rule in the ASC and HOPD is different.
ASC: As with surgeons, when either procedure is performed in the same operative session as another major ophthalmic surgery in an ASC (e.g., cataract surgery), then the multiple procedure rules apply and reimbursement for a second procedure is reduced by 50%.
HOPD: When either procedure is performed in the same operative session as another major ophthal-mic surgery (e.g., cataract surgery) in a HOPD, then the multiple procedure rule does not apply and payment is based on the allowed amount for APC 5492, a comprehensive APC. All covered Part B services on the claim are packaged with the primary J1 service for reimbursement, with few exceptions.
Provided Courtesy of Ellex (888) 846-4724
Last updated January 31,2019
The reader is strongly encouraged to review federal and state laws, regulations and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on all matters pertaining to reimbursement. The reader is also reminded that this information, including references and hyperlinks, can and does change over time, and may be incorrect at any time following publication.
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