Glaucoma is one of the main causes of permanent blindness. Patients usually require immediate surgery to maintain vision. This is why goniotomy has grown in popularity in the United States over the past several years as a minimally invasive glaucoma surgery (MIGS). It is widely adopted to treat mild-to-moderate open-angle glaucoma.
CPT code 65820 is used to report standalone goniotomy performed with modern surgical devices.
Our experts at MediBillMD have prepared this guide to explain what code 65820 represents, when it should be billed, the documentation requirements, applicable modifiers, and the key reimbursement guidelines every ophthalmology practice should know.
CPT Code 65820 – Description
CPT code 65820 refers to a goniotomy, a surgical procedure used to treat glaucoma.
During the surgery, the ophthalmic surgeon uses a blade or an approved surgical tool to make an incision in the limbus to enhance drainage of aqueous humor in the eye. This opening allows the trapped fluid to flow out more easily, reducing the pressure inside the eye.
The procedure is performed using small, specialized instruments through a tiny incision, so it does not require large surgical cuts, and the recovery time is typically 6 weeks.
This surgical technique is usually performed on children to cure congenital glaucoma. Additionally, CPT code 65820 has a 90-day global surgical period, so routine post-operative visits related to the surgery fall inside that window rather than being billed separately.
Scenarios Where CPT Code 65820 is Applicable
Here are the real-life cases where goniotomy is performed and billed with the CPT code 65820.
Goniotomy for Congenital Glaucoma
Suppose a 6-month-old infant exhibits severe tearing, light sensitivity, and enlarged corneas. After the checkup, he is diagnosed with primary congenital glaucoma. The pediatric ophthalmologist performs goniotomy to enhance aqueous fluid drainage and reduce intraocular pressure.
The procedure creates an opening in the trabecular meshwork. Therefore, CPT code 65820 is correctly reported to inform the insurance payer that goniotomy was performed.
Glaucoma Not Responsive to Conventional Treatment
Suppose a 3-year-old child is diagnosed with glaucoma and continues to have increased intraocular pressure. Physicians tried multiple drugs to cure this, but finally concluded with goniotomy after performing a thorough eye examination and gonioscopy.
Hence, an ophthalmologist performs the minimally invasive surgery to restore aqueous drainage. In this instance, the surgical procedure is precisely billed with CPT code 65820.
Bilateral Congenital Glaucoma
Let’s say a child has developed congenital glaucoma affecting both eyes. The surgeon first performs goniotomy on one eye and plans to operate on the second eye later to monitor recovery and lower the surgical risk.
In this case, each medically required goniotomy is recorded using CPT code 65820 and the proper laterality modifier in accordance with the payer’s requirements.
Applicable Modifiers for CPT Code 65820
The following is a list of modifiers applicable to CPT code 65820.
Laterality Modifiers (LT/RT)
Use these laterality modifiers to specify which eye the procedure was performed on. Modifier LT indicates the left eye procedure, whereas modifier RT indicates the right eye procedure.
Modifier 50
You may apply modifier 50 to the CPT code 65820 when goniotomy is performed on both eyes in the same session. Put a 1 in the unit field, submit a single line item with the surgical code followed by modifier 50, and enter twice the total charge.
Modifier 59
When a same-day procedure must be reported separately because it was performed on a different structure or satisfies a specific unbundling exception supported by documentation, you can use modifier 59 or X-modifiers (XE, XS, XP, or XU).
CPT Code 65820 – Billing & Reimbursement Guidelines
Follow these guidelines to secure reimbursement for goniotomy (represented by CPT code 65820).
Paperwork Proving Medical Necessity
Careful documentation is the key to accurate billing of CPT code 65820. Payers thoroughly review claims to confirm that the procedure was medically necessary and meets the CPT definition of a real goniotomy because goniotomy is a glaucoma surgery. Hence, billers must ensure that the supporting documentation includes the following information before filing a claim.
- The diagnosis of glaucoma
- Intraocular pressure readings
- Gonioscopy results
- Prior glaucoma medication or laser therapy treatments
- The clinical justification for a goniotomy
- Ophthalmologist’s surgical notes
These documents justify claim filing for reimbursement and help in proving medical necessity.
Global Surgical Period
Medicare has declared a 90-day global period for CPT code 65820. In most cases, routine post-operative care associated with the procedure cannot be paid individually and is included in the global payment. Additional compensation is only available for services that meet Medicare’s global surgery regulations.
Payer-Specific Policies
Goniotomy coverage may differ between commercial insurers and Medicare Administrative Contractors, especially if the treatment is part of minimally invasive glaucoma surgery (MIGS). Before scheduling or billing the procedure, always confirm coverage and prior authorization requirements, applicable diagnosis codes, and reimbursement rates.
Final Words
Although CPT code 65820 is simple to define, it is the easiest to bill inappropriately. 65820 is used to bill goniotomy, a minimally invasive glaucoma surgery that helps maintain vision by reducing intraocular pressure. Accurate representation of the process, a lower chance of claim denials, and prompt reimbursement are all guaranteed through proper coding.
Our ophthalmology billing services can assist in streamlining the coding and documentation process if glaucoma procedure denials are reducing the income of your practice.
