Reimbursement for the Molteno3 Glaucoma Drainage Device – (Nova Eye Medical)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR THE MOLTENO3®
GLAUCOMA DRAINAGE DEVICE
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Q Does Medicare cover implantation of the Molteno3® Glaucoma Aqueous Drainage Device?
A Yes, for medically necessary indications. The Molteno3 Glaucoma Drainage Device is intended to reduce intraocular pressure in “severe and complex cases” where medical and conventional surgical treatments have not been successful, to control the progression of disease.1
These cases sometimes have complicating conditions that must be taken into account, as well.
Q Is there more than one variety of the Molteno3 Glaucoma Drainage Device?
A Yes. There are two Molteno3 devices with different plate areas to suit the case: SS (185 mm2) and SL (245 mm2). A third model, the Molteno3 P1, is available for rare pediatric cases with microphthalmos (axial length <17mm). The devices are all non-valved, and can be inserted via translimbal or pars plana insertion options. Coding and reimbursement is the same for all models.
Q What CPT codes describe this procedure?
A There are two codes that may pertain, depending on whether a patch graft is used.
66179… Aqueous shunt to extraocular equatorial plate reservoir, ext. approach; w/o graft
66180… Aqueous shunt to extraocular equatorial plate reservoir, external approach; w/ graft
Q What is the surgeon’s reimbursement for 66179 and 66180?
A In 2020, the Medicare Physician Fee Schedule (MPFS) allowed amount for 66179 is $1,102 and for 66180 is $1,163. The specific allowed amount is adjusted by local wage indices.
Other payers set their own rates, which may vary considerably from Medicare amounts.
Q Does Medicare reimburse an ambulatory surgery center (ASC) for these procedures?
A Yes. The national ASC allowable amount for both 66179 and 66180 is $1,836. Local rates vary.
Q How is a hospital outpatient department (HOPD) paid for these procedures?
A Under OPPS, both 66179 and 66180 are assigned to the Ambulatory Payment Classification (APC) 5492; the 2020 national allowed amount is $3,818. These two codes are assigned status indicator J1.
Q What is the significance of the J1 indicator?
A The payment of multiple procedures is handled differently in the ASC and HOPD.
ASC: As with surgeons, when a 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 a procedure with the J1 indicator is performed in the same operative session as another major ophthalmic 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 the comprehensive APC, such as APC 5492. All covered Part B services on the claim are packaged with the primary J1 service for reimbursement, with few exceptions.
Q Is there separate payment for the implant?
A No. The implanted device is supplied by the facility and is included in the facility fee for both HOPD and ASC.
Q If a patch graft is used, are there any coding changes depending on the type of graft material?
A No, other than the use of the proper code (66180 instead of 66179). The surgeon may choose from donor cornea or scleral tissue, amniotic membrane tissue, or another suitable material. The graft material used does not affect coding or alter the reimbursement for either the surgeon or the facility. A graft procedure is not paid separately.
Q If a revision procedure is needed, is it covered?
A Yes, when medically necessary, Medicare will pay for revision of a previously implanted aqueous shunt. Again, there are two specific codes for use. They are based on whether a graft is used at the revision; whether a graft was used at the initial implantation doesn’t change the coding.
66184… Revision of aqueous shunt to extraocular equatorial plate reservoir, external approach; w/o graft
66185… Revision of aqueous shunt to extraocular equatorial plate reservoir, external approach; w/ graft
In 2020, the national MPFS allowed amount is $803 for 66184 and $865 for 66185.
The procedures are included in APC 5491. The HOPD allowable is $2,022; for an ASC it is $1,013.
Q Are there bundles to be aware of when using one of these codes?
A Yes. There are a number of ophthalmic procedures that may not be billed concurrently with any of these codes, particularly other glaucoma procedures, including MIGS. Established patient eye exam codes are also bundled with these codes. The codes are mutually exclusive with one another.
For a complete listing of NCCI edits, see the CMS website2 or ask us about a subscription to Corcoran’s Medicare Quick Reference Guide.
1 Molteno.com. Product Information Sheet. Link here. Accessed 06/26/20.
2 CMS. National Correct Coding Initiative (NCCI) Practitioner PTP Edits. Link here. Accessed 06/29/20.
Provided Courtesy of Nova Eye Medical (molteno@nova-eye.com)
Last updated July 22, 2020
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
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