Goniotomy Services eCBR

This Electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for beneficiaries receiving goniotomy services. 

eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

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Overview of Goniotomy Services — CPT® 65820
Glaucoma is a disease of the eye associated with increased intraocular pressure (IOP). The majority (about 90 percent) of patients with glaucoma have primary open-angle glaucoma (POAG), a chronic condition in which the IOP is elevated beyond a level compatible with the continued health and function of the eye, with a gonioscopically open angle and a decreased facility of outflow. 

Goniotomy, CPT® code 65820, is a surgery to lower eye pressure. When eye drops or laser are unable to adequately lower eye pressure, goniotomy may be considered. Goniotomy may allow for eye pressure control with or without the use of glaucoma medications. For patients who qualify for the procedure, goniotomy provides an alternative to bleb-forming glaucoma surgeries (trabeculectomy, Xen) or tube shunts. 

Since there is no specific CPT® code for gonio-puncture, or so-called micro-goniotomy procedures, the unlisted CPT® code 66999 (unlisted procedure, anterior segment of the eye) should be reported in these instances.

Documentation must comply with all legal and regulatory requirements applicable to Medicare claims. 

• NOTE: Documentation must comply with the elements outlined in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 14, Medical Devices, Section 10 Coverage of Medical Devices (PDF)

CMS works to eliminate improper payments in the Medicare Program and protect the Medicare Trust Fund, as well as beneficiaries from medically unnecessary services or supplies and their associated costs. CMS calculates a national Medicare fee-for-service (FFS) improper payment rate and improper payment rates by claim type and publishes the review results annually.

Methods
The metrics reviewed in this eCBR are the proportion of billing for claims for codes 66174, 66989 and 66991. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing at each level compared to your peers in Jurisdictions J and M.
 
Example of eCBR

 
Resources

• Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)
• Micro-Invasive Glaucoma Surgery (MIGS) 
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 14, Medical Devices, Section 10 Coverage of Medical Devices (PDF) 
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements, Section 30 Services paid under the Medicare Physicians Fee Schedule (PDF)
• Medicare Program Integrity Manual Publication 100-08, Chapter 13 (PDF)
  • Section 13.5.3 Evidentiary Content
  • Section 13.5.4 Reasonable and necessary provisions in LCDs
     
• Social Security Act (Title XVIII) Standard References:
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim