Medicare Reimbursement for Hydrus Microstent (Ivantis)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR THE HYDRUS MICROSTENT

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Q  What is the Ivantis Hydrus® Microstent?

A  The Hydrus Microstent is a small (the size of one eyelash), flexible device made of a biocompatible alloy of nickel and titanium (nitinol®) designed to be inserted into the trabecular meshwork and Schlemm’s canal using a unique delivery system. It functions as an “intracanalicular scaffold” to facilitate aqueous drainage from the anterior chamber.1

 

Q  What are the indications for the Hydrus Microstent?

A  As approved by the FDA in August 2018, the Hydrus Microstent “…is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure (IOP) in adult patients with mild to moderate primary open-angle glaucoma (POAG).” 2

 

Q  Is the Hydrus Microstent indicated for patients with glaucoma in the absence of cataract?

A  No. The FDA approval specifies “in conjunction with cataract surgery”. All other uses are off-label, considered experimental or investigational, and generally not covered.

 

Q  Does Medicare cover this procedure?

A  Yes, all Medicare Administrative Contractors (MACs) cover this procedure code when performed in accordance with the FDA approved directions for use, and in conjunction with medically necessary cataract surgery. Currently, these claims and the medical records are often subject to review by the MACs.

 

Q  Do other third party payers cover the 0191T code?

A  Yes, many other payers cover this procedure.3 Whenever possible, prior authorization should be obtained before scheduling a procedure.

 

Q  What is the global period for 0191T?

A  In the Medicare Physician Fee Schedule, there is no assigned interval for the global surgery period for 0191T. The global period for concurrent cataract surgery is 90 days, and it is not feasible to separate the follow-up for the two procedures. As a practical matter, the known interval outweighs the unknown interval.

 

Q  What does Medicare allow for 0191T?

A  Payment rates vary by type of provider and site of service. In 2018, the national Medicare allowed amounts for 0191T are:

In the ASC, the allowed amount for cataract surgery is $991.95, which is also paid but at 50% for the multiple procedure. In the HOPD, the C-APC does not permit an additional payment for cataract surgery – it’s bundled.4
From experience, there are considerable local variations in payment rates, particular for surgeons.

 

Q  Is physician reimbursement affected by the multiple procedure rule?

A  Maybe. Medicare and other third party payers are inconsistent on the application of the multiple procedure rule to physician reimbursement for cataract surgery with concurrent implantation of Hydrus or any other aqueous drainage device. Facility payments are not so capricious.

 

Q  May gonioscopy be billed at the time of surgery?

A  No. Gonioscopy is required during surgery to implant the Hydrus. CPT instructs that a code designated as a “separate procedure”, such as gonioscopy, should not be reported in addition to the code for the total procedure of which it is considered an integral component.

 

Q  Is there separate Medicare reimbursement for the Hydrus Microstent device?

A  No. Medicare payment for the aqueous drainage device is included in the facility reimbursement for APC 5492. On UB-04 claim form, use HCPCS code C1783 with revenue code 278 to identify the prosthetic device.5 On a CMS-1500 claim form, do not report a code for the device. For other payers, check your contracts concerning prosthetic devices.

 

Q  How should we bill if one surgeon removes the cataract and another implants the Hydrus Microstent?

A  If both surgeons are part of the same group, then only a single claim is needed and the aggregate payment is made to the group. When the surgeons are not part of the same group, then separate claims are required.

 

Q  Are there NCCI edits for CPT 0191T?

A  Yes. NCCI edits include paracentesis and injections as well as others. In addition, all edits in place for the concurrent cataract procedure pertain. Check NCCI edits periodically; they change quarterly.

 

1 Ivantis. The Hydrus Microstent. Accessed 07/16/18.
2 Ivantis. Press Release. 08/13/18.
3 Favorable payers for 0191T include Aetna, Cigna, UHC and most Blue Cross/Blue Shield plans.
4 Addendum B. Final OOPS Payment by HCPCS Code
5 CMS requires HOPDs to report C1783 (Ocular implant, aqueous drainage assist device) on Medicare claims for tracking purposes, although it does not garner additional payment.

 

Provided courtesy of Ivantis, Inc.

Last updated August 14, 2018

 

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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