Recently, one of the major areas for scope of practice expansion in optometry has been in the use of lasers in various surgical procedures. To date, 10 states have approved laser procedures.
With some exceptions, most states have added argon laser trabeculoplasty (ALT), selective laser trabeculoplasty (SLT), YAG capsulotomy, and laser peripheral iridotomy (LPI) to the list of services ODs may provide for their patients. In Oklahoma and Arkansas ODs are allowed to perform photorefractive keratectomy (PRK) procedures, which will not be covered in this article.
Any optometrist providing these services must know how to properly document medical necessity to show that it is reasonable and appropriate for their patients to undergo these procedures. Likewise, it is vital for ODs to know how to properly code and bill for the above-mentioned procedures so that they are paid properly and do not have to deal with denied claims.
This article will discuss coding for the three most common procedures: SLT/ALT, YAG capsulotomy, and LPI.
CPT codes for laser surgery procedures
The table below shows the CPT codes, global period, and 2022 average Medicare reimbursement for the three procedures.1
| CPT code | Procedure | Global period | Non-facility fee (2022) |
|---|---|---|---|
| 65855 | SLT/ALT | 10 days | $246.97 |
| 66821 | YAG capsulotomy | 90 days | $335.47 |
| 66761 | LPI | 10 days | $301.72 |
While it may be possible to perform these procedures bilaterally on the same date of service, the Medicare Medically Unlikely Edits (MUEs) generally limit them to one procedure per date of service. If both eyes are done on the same day, the claim will most likely be denied.
Another billing point to consider is that if a patient is seen for an office visit to determine whether a laser procedure is appropriate, and then the procedure is done on the same day, the office visit fee will be bundled into the laser procedure fee. This is not considered separately billable in most cases.
This table shows the coding modifiers that may be used for the three procedures.
| Modifier | Definition |
|---|---|
| RT or LT or 50 | OD, OS, or OU procedure |
| 78 | If YAG is done within the 90 day cataract surgery global period |
| 79 | If SLT, LPI, or YAG is done on the second eye within the global period of the first eye |
A review of the Local Coverage Determinations (LCDs) for Medicare provides a great deal of information about proper documentation and the appropriate ICD-10 diagnosis codes to use for each procedure.
Documenting medical necessity for laser surgery procedures
SLT/ALT coding guidelines
For SLT/ALT (65855), the three major criteria used to document medical necessity are the following:
- Utilizing SLT/ALT as the primary treatment for open angle glaucoma
- Primary open angle glaucoma (POAG) has been unresponsive to medications
- POAG with normal intraocular pressure (IOP) with evidence of continued optic nerve damage
It is important for the provider to document the symptoms, IOP, status of the anterior chamber angles, and optic nerve head assessment in the medical record.2,4
Other possible justifications for SLT/ALT (65855) may be: when the patient is unlikely or unable to comply with drug therapy due to physical or cognitive problems, if the patient suffers from adverse side effects from the medications, if the medications are ineffective, or if the medications affect the patient’s quality of life.
YAG capsulotomy coding guidelines
For YAG capsulotomy (66821), the four main criteria that may be used to document medical necessity are:
- Visual acuity (VA) decreased or glare affected to 20/30 or less
- Symptoms of decreased contrast sensitivity
- The amount of posterior capsule opacification
- Other possible causes of decreased VA after cataract surgery have been ruled out3,4
Except for rare circumstances, YAG capsulotomy may not be done within the 90 day global period after cataract surgery. Those exceptional circumstances are as follows:
- A posterior plaque or opacity that could not be removed safely during the cataract surgery
- Cataract remnants trapped within the lens capsule, requiring YAG for removal
- Posterior capsule contraction causes the intraocular lens (IOL) to be displaced3
When a YAG procedure is required during the 90 day cataract surgery post-op period, it should be billed with the modifier 78 to indicate that the procedure was an “unplanned” return of the patient for surgery during the global period for a related procedure (the initial cataract surgery).
It is important that the provider properly documents the criteria used for the medical necessity of coverage or justification for doing a YAG procedure during the 90 day global period.
LPI coding guidelines
For LPI (66761), the four major indications for the procedure are:
- Acute angle closure glaucoma
- Chronic angle closure glaucoma
- The fellow eye has had an acute angle closure
- Gonioscopy shows narrow/occludable angles3,4
Showing medical necessity for LPI would involve documenting the patient's symptoms, IOP, and anterior chamber angle status with gonioscopy. Since anterior segment OCT (92132) is not currently payable by Medicare and many major medical plans, a complete Interpretation and Report for the gonioscopy would likely pass an audit to show medical necessity.
Additionally, since an acute angle closure poses an emergent situation for the eyes, LPI is the most likely laser procedure which would necessitate doing the procedure on the same date of service as when the decision for surgery was made. In contrast, the other laser procedures would be safely scheduled for a different date of service.
Filling out the Informed Consent and Operative Report
The Informed Consent, which must be read and signed by the patient and a witness, should indicate the possible side effects and complications of the procedure and any questions asked by the patient should be answered to their satisfaction.
The Operative Report should include important information about the surgery itself. This includes listing what medications or anesthetics were administered during the procedure, as well as the laser strength settings, and the number of pulses used during the surgery.
It should also include a note about how well the patient tolerated the procedure and information about any instructions given to the patient regarding post-operative care and post-op visits. The provider should sign this document when the surgery has concluded.
Examples of Informed Consent and Operative Reports may be available from the laser vendors, as well as several online resources.
Conclusion
Knowing the documentation and coding requirements for these procedures, in addition to the steps necessary to incorporate the equipment and procedures into patient care, will allow ODs to smoothly add these procedures into their practices.
References
- Centers for Medicare and Medicaid Services. Search the Physician Fee Schedule, https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=1&CT=3&H1=65855&H2=66821&H3=66761&M=5. Published October 1, 2022. Accessed October 11, 2022.
- Clear Health Alliance Providers. Laser Trabeculoplasty and Laser Peripheral Iridotomy. https://provider.clearhealthalliance.com/dam/medpolicies/cha/active/guidelines/gl_pw_d093553.html. Published October 5, 2022. Accessed October 11, 2022.
- Corcoran S. Your guide to correct YAG coding. Ophthalmology Management. https://www.ophthalmologymanagement.com/issues/2014/october-2014/coding-amp;-reimbursement. Published October 1, 2014. Accessed October 11, 2022.
- Alliance Health Plan (avesis). Clinical Criteria Policy- YAG (Yittrium-Aluminum Garnet) Laser Surgery. https://www.alliancehealthplan.org/document-library/73229/. Published August 10, 2022. Accessed October 11, 2022.
