Medicare Reimbursement for Pattern Scanning Laser Trabeculoplasty
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR PATTERN SCANNING LASER TRABECULOPLASTY
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Q Does Medicare cover pattern scanning laser trabeculoplasty (PSLT) performed with Topcon’s PASCAL laser?
A Yes. Trabeculoplasty via laser is a covered procedure when it is medically necessary and supported in the patient’s medical record. PSLT is a form of laser trabeculoplasty that delivers a precise computer-guided treatment that applies a sequence of laser stimuli in a pattern configuration to the trabecular meshwork. Topcon notes that “the patterns readily align to match the curve of the trabecular meshwork, allowing faster and easier applications compared to other laser modalities.”1 The technology can be added as an option to some current Topcon lasers.
Q Should I consider PSLT as a primary treatment for glaucoma?
A Sometimes. When a patient cannot tolerate anti-glaucoma medications or cannot comply with instructions for use, then PSLT should be seriously considered. When anti-glaucoma meds are not affordable, laser trabeculoplasty (LT) has long been recognized as cost-effective. 2
Oftentimes, PSLT supplements current medications as an adjunctive therapy to lower IOP and possibly prevent glaucomatous damage.
Q What CPT code do we use to report PSLT for glaucoma?
A CPT code 65855, Trabeculoplasty by laser surgery, one or more sessions (defined treat-ment series) is used to report the service. This is the same code used for all types of LT, including argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT). CPT does not specify the type of laser. Also, report the location modifiers RT, LT, or 50 as appropriate.
Q How much does Medicare allow the physician for PSLT?
A When 65855 is performed in the surgeon’s office, the 2018 national Medicare Physician Fee Schedule allowed amount is $252 for participating providers. No facility fee is reported; the payment includes use of the laser.
When PSLT is performed in an ambulatory surgery center (ASC) or hospital outpatient department (HOPD), the surgeon’s Medicare allowable is reduced to $213.
Medicare fee schedule amounts are adjusted by local wage indices so actual payment amounts vary.
Q Does Medicare allow a facility fee to an ASC or HOPD for PSLT?
A Yes. Under current Medicare payment regulations, 65855 is eligible for a facility fee. It is paid under APC 5481. The 2018 national ambula-tory surgery center (ASC) allowed amount is $136; in the hospital outpatient department (HOPD), the allowable is $488. Allowed amounts are adjusted by local indices.
Q What is the global surgery period for PSLT?
A CMS assigns CPT 65855 a 10-day global period, so it is considered a minor procedure for reimbursement purposes. Most payers agree.
Q What about billing an office visit?
A The visit on the day of a minor surgery is regarded as part of the global surgery package unless there is a separately identifiable reason for the visit. If such a reason exists, the exam may be reportable with modifier 25. If the only reason for the visit is to determine the need for PSLT in the eye that is treated, that visit is not separately billable. For more information, see our FAQ on this subject.3
In the event of a return visit for an IOP spike in the treated eye during the 10-day global period, there is no visit to be billed. It would be considered to be postoperative care.
Q Can I be reimbursed for a repeat PSLT on the same eye?
A Usually. As a general rule, the overall effectiveness of PSLT can only be truly evaluated after 1-2 months, which is far beyond the 10-day global period. When the surgeon believes additional treatment is medically necessary outside of the global period, it is covered as long as proper documentation is present. Repeat treatments are widely supported in the literature as medically effective.
Q What about reimbursement for PSLT on the fellow eye during the global period of the first eye?
A Use modifier 79 with 65855 on your claim to indicate that this procedure is unrelated to the first. Location modifiers RT and LT are also helpful. The Medicare allowable remains the same.
Q Can PSLT be performed on both eyes on the same day?
A Yes, although it is not common. CPT guidelines for bilateral surgery and the Medicare guidelines for Medically Unlikely Edits (MUE) direct you to report bilateral PSLT as 65855-50 with a quantity of “1” for the surgeon claim. Facilities bill RT and LT on separate lines. Under the multiple procedure rules, reimbursement is based on 150% of the Medicare allowable for a single procedure. Most payers agree with this billing method.
1 Topcon. Pattern Scanning Laser Trabeculoplasty. Link here.
2 Stein, JD, Kim DD, et. al. Cost-effectiveness of Medications Compared With Laser Trabeculoplasty in
Patients With Newly Diagnosed Open-Angle Glaucoma. JAMA Ophthalmology. 2012;130(4):497-505. Link here.
3 Corcoran Consulting Group. FAQ on Modifier 25. Link for purchase here.
Provided Courtesy of Topcon Medical Systems (800) 223-1130
Last updated June 18, 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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