Coding: Billing Multiple Procedures Together

Identify only the codes you need.

Recently, you operated on a Medicare beneficiary with age-related cataracts and poorly controlled open-angle glaucoma. The narrative in the operative report describes inserting the cannula of the Hydrus delivery system (Ivantis) through a clear corneal incision. “Under gonioscopic visualization, the cannula tip first punctured the trabecular meshwork by means of a small incision and then advanced through the trabecular meshwork until it entered Schlemm’s canal. After observing that the distal cannula tip was properly positioned through the trabecular meshwork into Schlemm’s canal, the tracking wheel on the delivery system was advanced and released the microstent. Within a few seconds, blood entered the anterior chamber from the inlet of the Hydrus microstent. The phacoemulsifier handpiece was used to irrigate and aspirate the blood.”

The heading of your operative report identifies several procedures just before the description:

  • Phacoemulsification of cataract, right eye
  • Implantation of +20.5D aspheric monofocal intraocular lens, right eye
  • Gonioscopy, right eye
  • Goniotomy, right eye
  • Implantation of Hydrus microstent in Schlemm’s canal, right eye
  • Removal of blood from anterior chamber (AC) by irrigation, right eye
  • Intravitreal injection of triamcinolone and moxifloxacin, right eye

Your biller provides you with a list of corresponding CPT codes, comments, and questions:

  • 66984 vs 66982 (?): Phacoemulsification and implant IOL (Complex?)
  • 92020: Gonioscopy
  • 65820: Goniotomy
  • 0191T: Implantation of Hydrus microstent in Schlemm’s canal1
  • 65815 vs 65930 (?): Removal of blood from AC by irrigation (Blood clot?)
  • 67028: Intravitreal injection of triamcinolone and moxifloxacin
  • 66990 (?): Endoscopy add-on for goniotomy (Endoscope?)

Are all of these CPT codes appropriate for your claim to Medicare? Are any special modifiers needed to be maximally reimbursed? To answer these questions, there are many considerations. Table 1 organizes pertinent factors to help you thoroughly and thoughtfully respond to your biller. Ultimately, the responsibility for an accurate and compliant claim for reimbursement is yours, and the biller is your aid in that process. A key consideration related to compliance is requesting multiple payments for the same item or service. This occurs when separate billing codes are used for services that have an aggregate billing code2 or when “billing for each component of the service instead of billing or using an all-inclusive code.”3

Table 1: Schematic of Billing Considerations
Who is the provider? Surgeon, optometrist, physician assistant, anesthetist, ASC, or HOPD. Credentialing. Assignment. Scope of practice. CMS-1500 vs UB-04 claim form. Coding and billing rules vary. Participation status with payer and assignment of benefits. Eligibility to be reimbursed.
Any applicable CPT instruction? CPT contains parenthetical language and general instructions. CPT Assistant amplifies CPT standards. Potential use of modifier -59 with “separate procedure.” Code segregation vs inclusion of allied items and services. Code sequencing.
Who is the payer? Medicare, Medicaid, TRICARE, PPO, or vision plan. Billing policies differ. Statutory, regulatory, and contractual constraints. National Correct Coding Initiative edits. Medically unlikely edits. Global surgery periods. Modifiers. Exclusions from coverage.
Adherence to CMS billing instructions? Does the payer explicitly or implicitly follow CMS billing policies? Omit bundled items and services from claims, or append modifier GZ to flag as expecting a denial of reimbursement. Consider administrative burden and added complexity of modifier GZ.
Any additional payer policy? Covered vs noncovered items and services. Limitations on reimbursement tied to ICD-10 codes. Utilization limits. Financial waivers (eg, ABN, NEHB, MAO predetermination of benefits). Modifiers (ie, GA, GY, GZ).
Any professional society guidance? Meaning of “medically necessary.” Preferred practice patterns. Standards of care. Distinguish between new, emergent procedures and well-accepted, common procedures. Anticipate claims that may be challenged or that need added support or explanation. Follow prior authorization protocol where feasible.

Medical Terminology

A goniotomy is a cutting into, but not necessarily removing, the trabecular meshwork (TM). Since 1936, when the procedure was first described,4 goniotomy involved an incision spanning about 120° and not just a puncture of the TM.5 The operative report describes an incision through the TM to permit passage of the cannula into Schlemm’s canal rather than an arcuate incision of 4 clock hours. The goniotomy code, 65820, does not apply here.

Instructions in CPT

The section of the operative report on cataract surgery and implantation of a conventional monofocal intraocular lens is routine, and the concurrent minimally invasive glaucoma surgery does not make the cataract surgery “complex” because that term is used in CPT for 66982.6

CPT uses the phrase “separate procedure” to identify “a procedure or service that is normally performed as an integral component of a total service or procedure … separate procedure codes should not be coded in addition to the basic procedure code of which it is considered an integral component.”7 You and your biller note that “separate procedure” is part of the CPT description of gonioscopy (92020) and removal of blood from the AC (65815).

The operative note describes gonioscopy as a means to visualize the surgery and not something separate or unrelated. Likewise, it describes fresh bleeding into the AC (not a blood clot as described in 65930) immediately after inserting the microstent; evacuation of the blood with irrigation and aspiration is an incidental part of the basic implantation procedure. Neither CPT code should be part of your claim.

Current Procedural Terminology contains clear instructions on billing for the use of a surgical microscope. The CPT states, “Do not report 69990 in addition to the procedure where use of the operating microscope is an inclusive component (65091-68850).”7 The add-on code, +69990, does not apply for cataract surgery. Also, within the operative report, many instruments are mentioned, but endoscope is not one of them. The add-on code, +66990, does not apply in this case.

CMS Instructions

This patient is a Medicare beneficiary, and the CMS National Correct Coding Initiative billing edits apply. A quick check of the current edits shows intravitreal injection (67028) is bundled with cataract surgery (66984);8 however, the codes may be unbundled and both billed under certain circumstances that are described by modifier 59.9 In this case, there are no eligible reasons to unbundle 67028.

You and your biller address all the concerns, and your claim for reimbursement will contain 66984-RT, phacoemulsification and implant IOL, right eye, and 0191T-RT, implantation of Hydrus microstent in Schlemm’s canal, right eye. The sequence of the codes on a Medicare claim is irrelevant; modifier 51 is no longer required by Medicare to identify a secondary procedure. The claim processing by the Medicare Administrative Contractor automatically stratifies the procedures from highest to lowest based on the allowed amount, not your charge.


Proper billing is not a matter of identifying as many CPT codes as possible and letting the payer sort out what to pay. Follow a careful process to assess whether or not to include procedure codes on your claim. GP


  1. Corcoran Consulting Group, Medicare Reimbursement for the Hydrus Microstent. October 2018 . Accessed December 31, 2018.
  2. Federal Register, Vol 65, No 243, p 70138, 70142, Dec 18, 2000.
  3. Federal Register, Vol 65, No 194, p 59434, 59439, Oct 5, 2000.
  4. Barkan O. A new operation for chronic glaucoma. Restoration of physiological function by opening Schlemm’s canal under direct magnified vision. Am J Ophthalmol. 1936;19(11):951-966.
  5. Brandt, JD. Chapter 238 – goniotomy and trabeculotomy. Accessed December 31, 2018.
  6. Corcoran SL. Complex cataract surgery: getting a closer look. Ophthalmol Manag. 2015;19(11):8,14.
  7. American Medical Association. CPT/Current Procedural Terminology Professional Edition 2019. American Medical Association; 2018.
  8. Centers for Medicare & Medicaid Services. National Correct Coding Initiative, Edits for 66984.
  9. Centers for Medicare & Medicaid Services. Modifier 59 Article, . Accessed December 31, 2018.