Reimbursement

Coding and Reimbursement: US Healthcare Providers Only

Updated: July 30, 2018

Payer guidelines are subject to change without notice.

2018 Billing and Coding Guide with Sample Claim Forms

Approved Indications

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.
The iStent inject® Trabecular Micro-Bypass System Model G2-M-IS 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.

Coding Options

CPT®1 Codes

Product CPT Modifiers Revenue Code
iStent® 0191T; Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion -LT (left side), or
-RT (right side)
0360

Operating room services; general

iStent inject® 0191T; Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion

AND

0376T; 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)

-LT (left side), or
-RT (right side)-LT (left side), or
-RT (right side)

The iStent® procedure using codes 0191T, along with 0376T for iStent inject®, must be billed on the same claim with the appropriate cataract procedure.

Typically, only the anatomical modifiers should be appended to 0191T and 0376T. Medicare no longer requires the use of modifier -51 (Multiple Procedures) to indicate multiple procedures.

HCPCS Codes

Hospital outpatient departments (HOPDs) must report all items and services using the correct HCPCS codes. Failure to report the HCPCS code may result in incorrect payment. Some ASC claims to commercial payers may also require the inclusion of a HCPCS code. ASCs should review their payer provider contracts for guidance.

HCPCS Code Description Revenue Code
C1783 Ocular implant; aqueous drainage assist device 0278; other implants
L8612 Aqueous shunt

Diagnosis Codes

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.

The following possible ICD-10-CM diagnosis codes describe conditions that are consistent with the FDA labeled indication for iStent® and iStent inject®.

    • H40.1111 – Primary Open Angle Glaucoma, Right Eye, Mild Stage
    • H40.1112 – Primary Open Angle Glaucoma, Right Eye, Moderate Stage
    • H40.1121 – Primary Open Angle Glaucoma, Left Eye, Mild Stage
    • H40.1122 – Primary Open Angle Glaucoma, Left Eye, Moderate Stage
    • H40.1131 – Primary Open Angle Glaucoma, Bilateral, Mild Stage
    • H40.1132 – Primary Open Angle Glaucoma, Bilateral, Moderate Stage

Claims Submission Process

Each provider is responsible for ensuring all claims are accurately coded and submitted on a timely basis. Fully documented claims helps to minimize delay in proper reimbursement.

Coverage Highlights

iStent®
The iStent® is broadly covered by payers. Currently, all Medicare Administrative Contractors (MACs) have established positive coverage guidelines for the iStent®. Anthem, Aetna, Cigna, Humana, United Healthcare, and most local Blue Cross Blue Shield plans have also established positive coverage guidelines for the iStent®.
iStent inject®
As with most new and emerging technologies, payers will begin reviewing data and updating their coverage criteria upon FDA approval. Prior to publication of a coverage position, payers may assess claims on a case-by-case basis based on medical necessity.

Private payers may require a prior authorization before performing the iStent® procedure. Additionally, because Category III CPT Codes are often used to identify emerging technology, insurers unfamiliar with the iStent® or iStent inject® may request additional materials to support coverage when submitting claims.

Please check with your local Glaukos Regional Business Manager for the latest updates on coverage in your area.

2018 National Average Unadjusted Medicare Payment

CPT Code Descriptor

Physician

Ambulatory Surgical Center

Hospital Outpatient Department

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

Contractor Priced

$2573

Device intensive procedure paid at an adjusted rate (J8)

$3610

Comprehensive APC 5492

(J1)

CPT 0376T 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)

Contractor Priced

Packaged service or item (N1)

Items and Services Packaged into APC Rates; Paid under OPPS; payment is packaged into payment for other services (N)

 

PHYSICIAN: CPT Category III codes such as 0191T and 0376T are temporary codes that allow data collection for emerging technologies, services, procedures, and service paradigms. CPT Category III codes are not referred to the AMA-Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) are assigned to these codes.2 As a result, CMS does not establish payment levels for these services or procedures in the annual physician fee schedule, but leaves it to Medicare contractors to determine the rates.

Currently, 0191T is included in all Medicare Administrative Contractor (MAC) physician fee or carrier-priced published schedules. Please consult your local MAC’s website for applicable physician payment rates. Payment for the placement of a second iStent® device reported with 0376T should be established as payers begin processing claims. Like all Category III CPT Codes, physician payment rates for CPT codes 0191T and 0376T will be at each MAC’s discretion.

HOSPITAL OUTPATIENT DEPARTMENT: CPT code 0191T has a status indicator of “J1” and is assigned to a comprehensive APC, APC 5492 (Level 2 Intraocular Procedures). CPT code 0376T has a status indicator of “N” which indicates that the facility payment for this code is packaged into the APC rate for other services – in this instance, presumably APC 5492. CPT code 0376T is not a non-covered service, but rather, not a separately paid service for the facility.

Hospital outpatient departments must also report the appropriate device HCPCS code on all Medicare claims to ensure appropriate reimbursement. For more information on this, reference the “Device” paragraph in the “Coding” section above.

AMBULATORY SURGICAL CENTER: CPT code 0191T has a status indicator of “J8” and is designated as a device intensive procedure. CPT code 0376T has a status indicator of “N1” which indicates that the payment for this code is packaged.

ASCs do not report HCPCS codes to report implanted devices on claims sent to Medicare. Payment for a device is typically “packaged” into the payment for the ASC procedure.

Commercial: Physician and facility payment

Private payers each employ their own methodology to determine payment amounts for services based on the CPT, ICD-10 and HCPCS codes billed on the claim and payment will be contingent upon the contractual agreement.

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® and iStent inject® implantation, the associated cataract procedure and for the iStent® device itself. All HOPDs must include the iStent® device on their claim forms to payers in order to capture the full cost of providing the service.

While many commercial payers will package the device reimbursement with the surgical facility payment for 0191T, some commercial payer claims in the Ambulatory Surgery Center setting may pay a carve-out for the iStent® implant. A review of the specific payer’s requirement is recommended.

For additional questions specifically related to commercial payer contracts please contact us at iStentContractingHelp@glaukos.com.

GRASP (Glaukos Reimbursement Support and Assistance Program)

GRASP is available to assist iStent® users with coding, billing, and reimbursement questions and to provide additional support, including:

  • Prior authorization guidance
  • Letter templates
  • General coding and billing recommendations
  • Assistance with low-pay or denied claims
  • Guidance for commercial contracting issues

To engage with GRASP, please call (866) GRASP77 or (866) 472-7777 email us at GRASP@navigant.com


Glaukos provides this coding guide for informational purposes only and it is subject to change without notice. This guide is not an affirmative instruction as to which codes and modifiers to use for a particular service, supply, procedure or treatment and does not constitute advice regarding coding, coverage, or payment for Glaukos products. It is the responsibility of providers, physicians and suppliers to determine and submit appropriate codes, charges and modifiers for products, services, supplies, procedures, or treatment furnished or rendered. Providers, physicians and suppliers should contact their third-party payers for specific and current information on their coding, coverage, and payment policies. For further detailed product information, including indications for use, contraindications, effects, precautions and warnings, please consult the product’s Instructions for Use (IFU) prior to use. The information provided herein is without any other warranty or guarantee of any kind, expressed or implied, as to completeness, accuracy, or otherwise. This information is intended only to help estimate Medicare payment rates and product costs in the hospital outpatient department setting. All rates shown are national average Medicare rates and have not been adjusted for geographic variations in payment or other factors, such as sequestration.

1. CPT is a registered trademark of the American Medical Association (AMA). Copyright 2017 AMA. All rights reserved.

2. AMA, CPT Category III Codes, January 16, 2018 available at https://www.ama-assn.org/sites/default/files/media-browser/public/physicians/cpt/cpt-category3-codes-long-descriptors.pdf (accessed: June 22, 2018).

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