Streamline® Viscoelastic Injector – How to Code?

Date: April 20, 2022

Summary:   New World Medical’s new product, the Streamline® Viscoelastic Injector, raises interesting coding questions.  Standalone procedures with it should be reported on a claim for reimbursement as  unlisted procedure, anterior segment of eye (66999).  When injection of viscoelastic is incidental to another glaucoma procedure, it should not be reported at all.

Streamline® Viscoelastic Injector by New World Medical, Inc. is a single-use disposable cannula for use during ophthalmic surgical procedures to deliver small amounts of viscoelastic fluid.[1]  In a recent YouTube video by Malik Kahook, MD, he demonstrates how this instrument is used to inject a viscoelastic agent into Schlemm’s canal (SC).  The company’s website contains an educational video to describe the Streamline® Surgical System: the instrument, its design, and its functionality.  Glaucoma surgeons are not strangers to the use of viscoelastic in the eye as occurs with reversing hypotony.[2]  CPT 66020 (Injection, anterior chamber of eye [separate procedure]; air or liquid) is used to report that, however the Streamline® Viscoelastic Injector puts the viscoelastic behind the trabecular meshwork (TM) in SC and not in the anterior chamber (AC).  While there are many CPT code descriptors that contain the word “injection”, none fit this procedural description.  CPT instructs, “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”  In this case, use 66999 (Unlisted procedure, anterior segment of eye).  This topic was briefly touch upon in an article in EyeNet Magazine, a publication of the American Academy of Ophthalmology, that stated, “If you inject viscoelastic into a limited portion of the canal via an opening created through the trabecular meshwork, don’t use 66174.  Use 66999Unlisted procedure, anterior segment of eye.”[3]   CPT 66174 describes “Transluminal dilation of aqueous outflow canal; without retention of device or stent”.

In both videos, “goniotomy” is mentioned as a description of this procedure which deserves consideration.  Incisional goniotomy as originally described by Barkan[4] and Swan,[5] involves creation of a goniotomy cleft in “…one-quarter to one-third of the circumference of the angle [that] is treated…”.[6]  A number of instruments can be used to create a goniotomy cleft including one made by New World Medical, the Kahook Dual Blade.[7i]  It is fair to say that there is a substantial difference between an injection and a lengthy incision in TM, and that goniotomy (CPT 65820) is not accurate to describe the use of the Streamline® Viscoelastic Injector.

As a further consideration, the injection of viscoelastic into SC may be incidental to another minimally invasive glaucoma surgery such as implantation of a Hydrus® Microstent.  Then, a separate CPT code is not needed for the injection because it is part of a larger service and not distinct from it.

Why the affinity for the term goniotomy to describe a procedure performed with this new instrument?  At the present time, CPT 65820 enjoys favorable Medicare reimbursement for a surgeon and a facility.  Recent Medicare payment rate changes for other MIGS procedures has lowered reimbursement.  Enthusiasm for alternatives, such as goniotomy, is easy to appreciate, however improper use is not.

[1]  DHHS FDA 510(k) K211680   https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K211680

[2]  Chiam, PJ, Chen, X, Haque, MS, Sung, VC, Outcome of fixed volume intracameral sodium hyaluronate 1.4% injection for early postoperative hypotony after Baerveldt glaucoma implant  Clin Exp Ophthalmol 2018 Dec;46(9): 1035-1040  https://pubmed.ncbi.nlm.nih.gov/29934963/

[3] AAO Eyenet Magazine. Savvy Coder. March 2022, p. 73.

[4]  Barkan, O, Technic of Goniotomy  Arch Ophthalmol 1938;19(2):217-223   https://jamanetwork.com/journals/jamaophthalmology/article-abstract/613422

[5]  Swan, KC, Goniotomy-a Modified Lens and Technique  Arch Ophthalmol 1965;74(2):231-234   https://jamanetwork.com/journals/jamaophthalmology/article-abstract/628088

[6]  Lister, A  Technique of Goniotomy  Brit J Ophthal (1965) 49, 594   https://bjo.bmj.com/content/bjophthalmol/49/11/594.full.pdf

[7i]  AAO EyeWiki  Kahook Dual Blade: Ab Interno Trabeculectomy    https://eyewiki.aao.org/Kahook_Dual_Blade:_Ab_Interno_Trabeculectomy

We are available and happy to assist you with issues such as this and other topics related to eye care.  We’re proud to assist with questions related to 2021 changes on Evaluation and Management eye exam coding, the increased activity from payers (e.g., Private payers, and the CMS TPE, RAC, and SMRC reviews) so contact us if you need our help with these responses.  Stay safe in this challenging time.

Recent News

CMS Extends Deadline for MIPS 2023 Data Submission

CMS has extended the data submission period for the Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2023 performance year of the ...

Congress Passed bill for MPFS

The recent passing of a partial government funding bill by Congress on March 8 is important to Medicare beneficiaries. This bill includes policies aimed at addressing ...

Change to Processing for Telehealth Services Billed with POS 10

In calendar year (CY) 2024, the Centers for Medicare & Medicaid Services (CMS) issued a change to processing for telehealth services billed with POS 10. ...

Diabetes Cost Measure Misattributed to Ophthalmologists

The American Society of Cataract and Refractive Surgery (ASCRS), the American Society of Retina Specialists (ASRS) and the American Academy of Ophthalmology (AAO), met recently ...

Review Your 2022 MIPS Performance Feedback and Final Scores

The Centers for Medicare & Medicaid Services (CMS) has released the Merit-Based Incentive Payment System (MIPS) performance feedback and final scores for the 2022 performance ...

JZ Modifier Required July 1, 2023

The much-anticipated mandatory reporting of the JZ modifier for Part B Medicare begins July 1, 2023.  The new Medicare policy can be found here.  The ...

Cigna Hits the Brakes on Their New Modifier 25 Policy

Following fierce opposition from the physician community, the insurer Cigna announced today a delay in implementing a policy (PDF) that would have required submitting medical ...

Medical Consulting Group and Corcoran Consulting Group Announce Merger

Springfield, MO, April 27th, 2023. Medical Consulting Group (MCG), a provider of consulting services to ophthalmic practices and companies, and Corcoran Consulting Group (CCG), a ...

IHEEZO Gel gains Medicare Pass-Through

On March 13, 2023, Harrow® announced that the Centers for Medicare & Medicaid Services (CMS) has approved transitional pass-through reimbursement status for chloroprocaine hydrochloride ophthalmic ...

Cigna Change Modifier 25 Policy

As a result of a recent review, Cigna has announced it will require the submission of office notes with claims submitted for evaluation and management ...

Congress makes positive adjustments that affect ophthalmologists

In this Healio Video Perspective from Hawaiian Eye 2023, Kevin J. Corcoran, COE, CPC, CPMA, FNAO, discusses ophthalmic economic and regulatory updates for the year. ...

HHS Extends Covid-19 PHE

On Thursday, October 13, the U.S. Department of Health & Human Services (HHS) Secretary Xavier Becerra extended the nation's COVID-19 PHE for an additional 90 ...

Noridian Changes to Goniotomy LCD

Noridian has made changes to their Goniotomy coverage policy effective October 1st, 2022. It states: “Since there is no specific CPT® code for goniopuncture or ...

2021 MIPS Performance Feedback, 2021 MIPS Final Score, and 2023 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2021 performance year, ...

Telehealth Place of Service Update

With a recent change to telehealth billing, billers need to be aware of an additional Place of Service code. What changed? Effective January 1, 2022, ...

Extension of Telehealth Flexibility

Last week, the U.S. House of Representatives approved legislation to further extend the Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. If ...

AETNA No Longer Requiring Prior Authorization for Cataract Surgery

The American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO) have spearheaded a year-long effort to remove the policy that ...

2021 MIPS Final Score Preview Now Available

The Centers for Medicare & Medicaid Services (CMS) has opened the Final Score Preview period for the Merit-based Incentive Payment System (MIPS).  You can now ...

Guidance for Coding Goniotomy

Summary:   Two new ophthalmic surgical products have attracted interest from surgeons:  Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos).  In both cases, ...

CIGNA Changes Their Modifier 25 Policy

As a result of a recent review, CIGNA will require the submission of office notes with all claims submitted with evaluation and management (E/M) CPT ...

CMS Reweights Scoring for Cost Category for Groups in 2021 Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) announced on Monday, April 25th, that ALL eligible MIPS providers will automatically receive re-weighting of the Cost ...

IACCESS™ Trabecular Trephine – How to Code?

Summary:   Glaukos’ new product, the IACCESS™ trabecular trephine, raises interesting coding questions.  Standalone procedures should be reported on a claim for reimbursement as unlisted procedure, ...

HHS Extends the Public Health Emergency Waivers

On April 12, 2022, Secretary of Health and Human Services Xavier Becerra again renewed the public health emergency declaration that was initiated at the end ...

CMS re-opens MIPS Hardship Exception for Groups, Virtual Groups, and APM entities

The Centers for Medicare & Medicaid Services (CMS) announced March 3 that they re-opened the 2021 Extreme and Uncontrollable Circumstances (EUC) application for those submitting ...