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Question: When our ophthalmic surgeon performs goniotomy in connection with the insertion of an aqueous drainage device into the trabecular meshwork, is it appropriate to report 65820?

Iowa Subscriber

Answer: No. Code 65820 (Goniotomy) is not typically reported in addition to other angle surgeries such as 66989 (Extracapsular cataract removal … complex … with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more), 66991 (Extracapsular cataract removal … with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more), or 0671T (Insertion of anterior segment aqueous drainage device into the trabecular meshwork …)).

In such cases, you should only report 66989, 66991, or 0671T, which describe inserting the aqueous drainage device, as the device insertion includes the incision through the trabecular meshwork and, therefore, is incidental to the goniotomy service. But “if extensive or multiple incisions larger than punctures of the trabecular meshwork are performed away from the drainage device and over an area of three or more clock hours, goniotomy may be reported,” according to CPT^® Assistant (August 2022).

Medicare guidelines echo this, as they regard stent insertion as “medically reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery.”  However, device insertion for “more invasive, external filtration glaucoma surgeries such as trabeculectomy or external aqueous drainage implants …” is “considered not reasonable and necessary at this time” (see, for example, Local Coverage Determination (LCD) >37244 Micro-Invasive Glaucoma Surgery (MIGS).

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC