Unlisted Codes and ASC, APC (or DRG)

 

Glaukos (GKOS): Headwinds vs. Tailwinds

John Leppard, 202-756-7703 jleppard@washingtonanalysis.com

A potentially overlooked headwind in the recent billing article update by Medicare Administrative Contractor (MAC) Palmetto, implying that Glaukos’ (GKOS) iStent should not be used with its new iAccess microgoniotomy product, is its concurrent instruction that, “since there is no specific CPT code for goniopuncture, or so-called microgoniotomy procedures, the unlisted CPT code 66999 should be reported in these instances.” As an unlisted procedure code, CPT 66999 is currently excluded from Medicare payments in ASCs, no MACs list a corresponding professional fee amount for its use, and ~99% of such claims [N = 5,052] were denied in the most recently available claims year (CY20). While other MACs have not yet followed Palmetto’s lead to such an explicit extent [see Novitas & First Coast below], documentation requirements, independent coding reviews [June 22, April 19], and provider uncertainty suggest that iAccess volumes – whether standalone or in combination with iStent – may be limited until there is greater clinical data on appropriate patient populations. As outlined in our July 14 note, however, we remain bullish on coverage / reimbursement for the recently approved iStent Infinite and the launch of iDose (mid-CY23).