Reimbursement

As a service to our customers, Glaukos provides a reimbursement and billing guide

reimbursementThe following reimbursement information is intended to provide healthcare professionals with information related to billing, coding, and reimbursement requirements that may apply to Glaukos products. It is being provided for general informational and educational purposes only, and is not intended, and does not constitute, reimbursement or legal advice. Use of codes identified here does not guarantee coverage or payment at any specific level and is not intended to increase or maximize payment by any payer. Laws, regulations and coverage policies are complex and updated frequently.

In addition, reimbursement policies vary widely from insurer to insurer and will reflect different patient conditions. You should check the current law and regulations and insurer’s policies to confirm the most current coverage, coding or billing requirements. Any questions should be directed to your attorneys or reimbursement specialist. The healthcare professional is responsible for all aspects of reimbursement, including using codes that accurately reflect the patient’s condition, procedures performed, and products used and ensuring the veracity of all claims submitted to third party payers.

• Approved Indication
• Coding Highlights
• Coverage Highlights
• Payment Highlights

Approved Indication

The iStent® Trabecular Micro-Bypass Stent (Models GTS100R and GTS100L) is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure (IOP) in adult patients with mild-to-moderate open-angle glaucoma currently treated with ocular hypotensive medication.

Coding Highlights

CPT Codes

Category III CPT codes are temporary codes that describe emerging technologies or services. Physicians and facilities need to establish a charge amount to be submitted with a Category III CPT code. Category III CPT codes are eligible for coverage and reimbursement by payers. When Category III CPT codes are submitted on claims, they may be subject to manual review by payers to make a determination on medical necessity and therefore payment. Coverage and reimbursement is not guaranteed, and the use of such codes may require additional documentation to be submitted to payers in order to justify the medical necessity of the procedure performed.

The table below identifies the possible CPT code(s) that may be used to describe the iStent® implantation procedure. Category III CPT code 0191T became effective for use July 1, 2008 and describes the insertion of glaucoma drainage devices using an ab-interno approach. Physicians and facilities are responsible for accurately selecting CPT procedure codes to describe the procedures performed.

CPT CODE Description
0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork

The iStent® device is indicated for use in conjunction with cataract surgery. Standard cataract surgery with implantation of an IOL is most commonly reported with CPT code 66984, although a number of other CPT codes may apply depending on the actual services performed.

HCPCS and Revenue Codes

Category III CPT codes are temporary codes that describe emerging technologies or services. Physicians and facilities need to establish a charge amount to be submitted with a Category III CPT code. Category III CPT codes are eligible for coverage and reimbursement by payers.

The following HCPCS code(s) may be used by ASCs and hospital outpatient departments (HOPDs) to report the iStent® device itself.

HCPCS CODE Description
C1783 Ocular implant, aqueous drainage assist device

The following revenue code(s) may be used to report the iStent® device in the HOPD setting of care on a UB-04 facility claim form. Revenue codes are used for tracking purposes and are not reimbursable codes.

Setting of Care Revenue code Description
Hospital Outpatient 274 Prosthetic Implant
Hospital Outpatient 278 Other Prosthetic Implant

Diagnosis Codes

The following table includes ICD-10-CM diagnosis codes that describe conditions that may be reported on iStent® claim forms.

ICD-10-CM Code Description
H40.1111 or H40.1112 Primary open angle glaucoma, mild stage or moderate stage, right eye
H40.1121 or H40.1122 Primary open angle glaucoma, mild stage or moderate stage, left eye
H40.1131 or H40.1132 Primary open angle glaucoma, mild stage or moderate stage, bilateral

The ICD-10-CM diagnosis codes listed in this table may be commonly associated with iStent® patients but are not intended to be an exhaustive list of all possible diagnosis codes. Please refer to the ICD-10-CM book for a comprehensive list of diagnosis codes.

Note that in all cases, it is ultimately the responsibility of the provider to report the ICD-10-CM diagnosis code that most accurately describes the patient’s condition.

Coverage Highlights

The iStent® represents the latest technology in treating glaucoma and is broadly covered by payers. Currently all Medicare Administrative Contractors have established positive coverage guidelines for the iStent®. United Healthcare, Aetna, most local Blue Cross Blue Shield plans and other local carriers have also established positive coverage guidelines for the iStent®. Glaukos continues to work with payers to obtain specific guidance on the iStent® for its customers. Please check with your local Glaukos Regional Business Manager for the latest updates on coverage policies in your area.

In the absence of established coverage policies, payers will review claims and determine coverage on a case-by-case basis. Private payers may need to be contacted to obtain prior authorization before performing procedure(s). Additionally, because Category III CPT codes are often used to identify emerging technology, insurers unfamiliar with the iStent® may request additional materials to support coverage when submitting claims.

For information regarding payer coverage in your area, please consult with your Glaukos Regional Business Manager.

Payment Highlights

Medicare Payment – Physician

Because Category III CPT codes typically reflect new and emerging technologies, CMS does not establish national payment rates on the Medicare Physician Fee Sschedule for these types of procedures.

Payment for Category III CPT codes will be determined by individual Medicare contractors on a case-by-case basis. Physicians need to establish a charge amount to be submitted with these types of codes. Claims for professional services submitted under Category III CPT codes are often manually reviewed by payers.

The payment methodology for a procedure submitted under a Category III CPT code varies. In some instances, Medicare will calculate payment based on the amount charged on the claim. In other cases, payment will be determined by comparing work involved with the iStent® to other similar procedures.

Medicare Payment – Facility

To determine the payment amount for the iStent® procedure and associated cataract procedure in the ambulatory surgery center (ASC) care setting and to obtain additional information related to the ASC Payment System, visit the CMS website: http://www.cms.gov/center/asc.asp

To determine the payment amount for the iStent® procedure and associated cataract procedure in the HOPD and to obtain additional information related to HOPPS, visit the CMS website: http://www.cms.gov/HospitalOutpatientPPS/01_overview.asp

CPT code 0191T is assigned to Ambulatory Payment Classification C-APC 5492.

Table 8 Comprehensive APC assignment for CPT 0191T

APC Description
C-APC 5492 Level 2 Intraocular Procedures

Facilities are encouraged to report the iStent® device on their claim forms to payers as this permits appropriate tracking of the full costs of the procedure(s).

Private Payer Payment – Physician

Payment for Category III CPT codes will be determined by private payers on a case-by-case basis. Physicians need to establish a charge amount to be submitted with these types of codes. Claims for professional services submitted under Category III CPT codes are often manually reviewed by payers.

The payment methodology for a procedure submitted under a Category III CPT code varies. In some instances, private payers will calculate payment based on the amount charged on the claim. In other cases, payment will be determined by comparing work involved with the iStent® to other similar procedures.

Payment rates for specific CPT codes may be obtained from the payer’s published physician fee schedule or by contacting the payer directly.

Private Payer Payment – Facility

Private payers each employ their own methodology to determine payment amounts for facility services based on the CPT, ICD-9 and HCPCS codes billed on the claim. Facility billing departments should check the service contracts with individual private payers or contact each payer directly to verify the applicable reimbursement methodologies and/or amounts for the iStent® implantation, the associated cataract procedure and for the iStent® device itself. As with Medicare, it is important that facilities include the iStent® device on their claim forms to payers in order to capture the full cost of providing the service.

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