Billing and Coding: Insertion of anterior segment aqueous drainage device,
without extraocular reservoir, external approach (0192T 66183)

**Abstract:**  
  
Glaucoma filtering surgery is indicated when glaucomatous damage progresses
despite pharmacological and/or surgical treatment. Trabeculectomy is the most
widely used form of filtering surgical treatment for primary open-angle
glaucoma. Glaucoma drainage implants designed to shunt the aqueous fluid
posteriorly represent an alternative method for lowering intraocular pressure
in glaucomatous patients and are commonly used in refractory glaucoma or after
failure of filtration surgery.  
  
Since the first mini shunt device was approved by the Food and Drug
Administration (FDA) for marketing in March 2002, over 14,000 implantations
have been performed. However, there has been disagreement in the ophthalmology
community regarding the correct coding for this procedure. The majority of
ophthalmologists billed Current Procedural Terminology (CPT) code _66180
(Aqueous shunt to extraocular reservoir [eg, Molteno, Schocket, Denver-
Krupin]), with some using 66172 (Fistulization of sclera for glaucoma;
trabeculectomy ab externo with scarring from previous ocular surgery or trauma
[includes injection of antifibrotic agents]) or 66999 (Unlisted procedure,
anterior segment of eye)._ Because of this disagreement, the American Medical
Association (AMA) CPT Panel developed a new Category III CPT code, _0192T
(Insertion of anterior segment aqueous drainage device, without extraocular
reservoir, external approach),_ effective for services rendered on or after
July 1, 2008 thru December 31, 2013. Effective January 1, 2014 CPT code 66183
should be used for the insertion of anterior segment aqueous drainage device..
The appropriate ICD-10-CM codes are listed below in the covered ICD-10 code
section. The device used must be FDA approved, such as the Ex-PRESSTM mini
shunt (Optonol).  
  
**Indications:**  
  
An anterior segment aqueous drainage device, without extraocular reservoir,
implanted under a partial thickness scleral flap may be a safe alternative or
adjunct to standard guarded trabeculectomy, especially for patients with
advanced glaucoma in need of low intraocular pressures with a high risk for
hypotonous complication.  
  
 **Limitations:**  
  
Other indications for 0192T and/or 66183 remain investigational or not
medically necessary.  
  
 **Coding Guidelines:**  
  
 _**General Guidelines for claims submitted to Part A or Part B MAC:**_  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.  
  
_Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines_  
  
An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
_Medicare Claims Processing Manual_ , Chapter 30, for complete instructions.  
  
Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.  
  
The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they **do have** an ABN signed by the
beneficiary on file. Modifier GA applies only when services will be denied
under reasonable and necessary provisions, sections _1862(a)(1), 1862(a)(9),
1879(e), or 1879(g)_ of the Social Security Act. Effective April 1, 2010, Part
A MAC systems will automatically deny services billed with modifier GA. An
ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that
he/she accepts responsibility for payment. The -GA modifier may also be used
on assigned claims when a patient refuses to sign the ABN and the latter is
properly witnessed. For claims submitted to the Part A MAC, occurrence code 32
and the date of the ABN is required.  
  
Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions _other_ than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
Part A MAC systems will automatically deny the services.  
  
The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they **have not** had an ABN signed by the
beneficiary.  
  
If the service is statutorily non-covered, or without a benefit category,
submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not
required for these denials, and the limitation of liability does not apply for
beneficiaries. Services with modifier GY will automatically deny.  
  
The anatomic modifiers left (-LT) or right (-RT) should be appended to the
procedure code. The -50 modifier is not to be appended to this code as two
eyes should not be done on the same day.  
  
Only CPT code 0192T should be reported for insertion of the anterior segment
aqueous drainage device for dates of service July 1, 2008 thru December 31,
2013. Effective January 1, 2014 CPT code 66183 should be reported for
insertion of the anterior segment aqueous drainage device. . Do not report CPT
codes 66170, 66172, 66180 or other procedure codes formerly used for the
insertion of this device.  
  
 _**For claims submitted to the Part B MAC:**_  
  
Claims for 0192T/66183 are payable under Medicare Part B in the following
places of service: office (11), inpatient hospital (21), outpatient hospital
(22), ambulatory surgical center (24) and independent clinic (49).  
  
 _**For claims submitted to the Part A MAC:**_  
  
 _Hospital Inpatient Claims:_

  * The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. _The principal diagnosis is the condition established after study to be chiefly responsible for this admission.  
_

  * The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  *  
  * For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, _Medicare Claims Processing Manual,_ Chapter 25, Section 75 for additional instructions.)

_Hospital Outpatient Claims:_

  * _The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67._ If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider _should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).  
_

  * The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.