Medicare Reimbursement for Selective Laser Trabeculoplasty (Ellex)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR SELECTIVE LASER TRABECULOPLASTY
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q Does Medicare cover selective laser trabeculoplasty (SLT)?
A Yes; trabeculoplasty performed with a frequency doubled Nd:YAG laser1 is a covered procedure when it is medically necessary and supported in the patient’s medical record.
Q Should I consider SLT as a primary treatment for open-angle glaucoma?
A Yes. The only Medicare Administra-tive Contractor (MAC) with an active policy, First Coast Service Options, covers SLT as a primary treatment for OAG.2 The American Academy of Ophthalmology’s Preferred Practice Pattern (AAO PPP) for primary open-angle glaucoma states: “Laser trabeculoplasty can be considered as initial therapy in selected patients.”3 One large (718 patients), observer-masked, randomized clinical trial followed patients over 36 months and found that more SLT-primary patients were at or below their desired target IOP than the group given only eye drops. The investigators went so far as to recommend a change in policy allowing primary SLT.4 The literature also supports SLT as a cost-effective alternative to medications.5,6
Some third party payers only authorize SLT if the patient cannot tolerate anti-glaucoma medications or will not comply with eyedrops.7 Document drug intolerance or noncompliance in the medical record prior to SLT. High medication cost is a potential barrier and increases noncompliance.8
At other times, SLT supplements current medica-tions to prevent damage and can often reduce the medication burden for the patient.
Q What CPT code do we use to report SLT for glaucoma?
A CPT code 65855, Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) is used to report the service. This is the same code used for argon laser trabeculo-plasty (ALT) since CPT is agnostic to the type of laser.
Q What is the Medicare physician reimbursement for SLT?
A When SLT is performed in the physician’s office, the 2019 national Medicare Physician Fee Schedule allowed amount is $253 for participating providers. When SLT 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 for SLT?
A Yes. Under current Medicare regula-tions, 65855 is eligible for a facility fee. The 2019 national ambulatory surgery center (ASC) allowed amount is $137; in the hospital outpatient depart-ment (HOPD), the allowable is $496. Allowed amounts are adjusted by local indices.
Q What is the global surgery period for SLT?
A CMS assigned CPT 65855 a 10-day global period, so it is classified as a minor pro-cedure for reimbursement purposes.
Q Is an office visit billable on the same day as SLT?
A Sometimes. The visit on the day of a minor surgery is a 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 SLT, that visit is not separately billable. For more information, see our FAQ on this subject.9
Q Can I be reimbursed for a repeat SLT on the same eye?
A Yes, but not within the 10-day global period. In general, the effectiveness of SLT can only be evaluated after 1-2 months, which is far beyond the 10-day global period.
When the surgeon believes additional treatment is medically necessary and properly documents the rationale for repeating it outside of the global period, it is covered. Repeat treatments are supported in the literature as effective.10,11
Q What about reimbursement for SLT on the fellow eye during the global period of the first eye?
A Use modifier 79 with 65855 on your claim to indicate that the second SLT procedure is unrelated to the first. Location modifiers RT or LT are also helpful.
Q Can SLT be performed on both eyes on the same day?
A Yes, although it is not common. CPT guidelines for bilateral surgery and recent Medicare guidelines for Medically Unlikely Edits (MUE) direct you to report bilateral SLT as 65855-50 with a quantity of “1” for the surgeon; facilities generally report 2 lines with RT and LT. Under the multiple procedure rules, reimbursement is based on 150% of the Medicare allowable for a single procedure. Most other payers agree.
1 Selective Laser Trabeculoplasty: 10 Commonly Asked Questions. Glaucoma Research Foundation. Link here.
2 First Coast Service Options (FCSO). LCD #L33917 on Laser Trabeculoplasty. Rev. eff. date 10/01/16. Link here.
3 AAO. Preferred Practice Pattern. POAG. Link here.
4 Gazzard, G, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019 Apr;13:393(10180):1505-16. Link here to abstract.
5 Iwach AG. Selective Laser Trabeculoplasty: Current Role in Glaucoma Management. Presentation at American Academy of Ophthalmology meeting, 2012. Posted December 13, 2012. Link to video here.
6 Lee R. and Hutnik CM. Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication. Can J Ophthalmol. 2006 Aug; 41(4):449-56. Link to abstract.
7 Francis BA, Ianchulev T et al. Selective laser trabeculo-plasty as a replacement for medical therapy in open-angle glaucoma. Am J Ophthalmol. 2005 Sep; 140(3):524-5. Link to abstract.
8 Eaddy MT, et al. How Patient Cost-Sharing Trends Affect Adherence and Outcomes. Al Literature Review. Link here.
9 Corcoran Consulting Group. FAQ on Modifier 25. Link here for purchase.
10 Lai J and Bournais TE. Repeatability of Selective Laser Trabeculoplasty (SLT). Invest Ophthalmol Vis Sci. 2005; 46: E-abstract 119. Link here.
11 Hong BK, Winer JC et al. Repeat selective laser trabeculoplasty. J Glaucoma. 2009 Mar; 18(3):180-3. Link to abstract.
Provided Courtesy of Ellex (800) 824-7444
Last updated May 14, 2019
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.
© 2019 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com