Medicare Reimbursement for iStent Inject
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR iSTENT INJECT
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Q How does iStent® inject® differ from the earlier iStent® trabecular micro-bypass system?
A iStent inject creates two patent bypass pathways through the trabecular meshwork – the main source of resistance for aqueous outflow – resulting in multi-directional flow through Schlemm’s canal. iStent inject is much smaller than the original iStent, straight rather than angled, has a smooth surface without retention arches, 33% smaller caliber lumen, and the inserter delivers two stents instead of just one.
Q When is iStent inject, using two stents, indicated?
A As approved by the FDA in June, 2018, iStent inject is indicated for use in conjunction with cataract surgery for the reduction of IOP in adult patients with mild to moderate open-angle glaucoma. All other uses are off-label and experimental or investigational.
Q Does Medicare cover implantation of a second iStent by a surgeon?
A For most Medicare jurisdictions, only implantation of the first iStent at the time of cataract surgery is covered; the surgeon’s time and expertise to implant the second iStent is not covered. Only Wisconsin Physician Services (WPS) has a local coverage determination policy that covers implanting a second iStent. A number of new LCDs are pending; check your local MAC for specific information.
Q What CPT codes describe implantation of any iStents?
A A Category III CPT code, 0191T applies for the first iStent. It reads, “Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork.”
A second Category III code, +0376T, applies when an additional iStent is implanted in the same session. This code is defined as, “Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork; each additional device insertion (list separately in addition to code for primary procedure).” This add-on code is only used in conjunction with 0191T.
Q What is the payment for implanting a second iStent where it is covered?
A The 2018 and 2019 national Medicare Physician Fee Schedules (MPFS) do not assign RVUs or a payment rate to iStent procedures – either the first or second. The MAC determines the amount of reimbursement.
Q What is the global surgery period for 0191T and +0376T?
A As a Category III code, there is no specified global period for 0191T or +0376T in the Medicare Physician Fee Schedule. The global period for concurrent cataract surgery is 90 days. As a practical matter, the known interval outweighs the unknown interval.
Q What is the Medicare facility payment for a single iStent?
A In 2018, the Medicare allowed amounts for 0191T are:
- ASC Facility Fee …………….. $2,573.27
- HOPD Facility Fee …………… $3,610.75
Because the known values are higher than the allowed amounts for the concurrent cataract surgery, 0191T ought to be the primary procedure. These amounts are adjusted in each locality by local wage indices and are additionally subject to payer restrictions which can vary considerably.
Q What is the Medicare facility payment for a second iStent?
A For both the ambulatory surgery center (ASC) and the hospital outpatient department (HOPD), under Medicare’s Outpatient Prospective Payment System, the payment for the first iStent includes the second one. The second iStent is bundled with the first. No separate reimbursement is available, and the beneficiary may not be charged.
Q Is there separate Medicare reimbursement for the iStent device?
A No. Medicare payment for the iStent is included in the facility reimbursement for APC 5492. On UB-04 claims, use HCPCS code C1783 and revenue code 278, together with 0191T, to report the iStent procedure. On the CMS-1500 form for ASCs, show 0191T and +0376T.
Q May a surgeon ever bill the patient directly for implanting a second iStent?
A Yes, but only when the MAC defines the procedure, +0376T, as not covered. Explain to the patient why a second iStent is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
- An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
- For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN form.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
This approach applies only to the surgeon. The ASC and HOPD are subject to OPPS, which treats a second iStent as bundled with the first. Other payers set their own coverage rules.
Q Are there any NCCI edits or bundles for CPT 0191T?
A Yes; NCCI edits include paracentesis and anterior chamber injections, as well as others. In addition, all edits in place for the concurrent cataract procedure pertain. Check NCCI edits periodically as they change quarterly. Most third party payers follow NCCI edits, but not all; check your payer contracts.
Provided Courtesy of Glaukos Corporation (800) 452-8567
Last updated November 20, 2018
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, etc. 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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