68841
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.48
Facility
$27.39
Non-Facility
$38.75
Documentation Required
- Claims must report the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures or the appropriate bilateral modifier for bilateral procedures; documentation on the claim itself (modifier placement) is required to avoid denial.
- The policy does not specify additional medical record forms or certifications; compliance is determined by correct coding/modifier reporting on the claim.
- Pre-operative documentation of diagnosis (e.g., OAG/POAG, OHT, refractory glaucoma) and indication for surgery (e.g., inadequate IOP control on medical therapy, need for surgical intervention).
- Pre- and post-operative intraocular pressure (IOP) measurements, including medicated IOP and, where performed, unmedicated/post-washout IOP or mean diurnal IOP (many studies used medicated and post-washout IOPs and mean diurnal IOP as endpoints).
Key Coverage Criteria
- Claims for CPT/HCPCS codes describing services on anatomic structures that can be distinguished as left or right must include the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures.
- Bilateral procedures must be indicated by the appropriate bilateral modifier (use the payer- or code-specific bilateral modifier rather than -RT/-LT).
- CPT codes whose descriptions explicitly state 'unilateral or bilateral' do not require additional laterality modifiers.
- Laser trabeculoplasty for treatment of members with refractory primary open-angle glaucoma (POAG) when first-line drugs (e.g., latanoprost or timolol) and second-line drugs (e.g., brimonidine or dorzolamide) have failed to control intra-ocular pressure (IOP).
- FDA‑approved aqueous drainage/shunt implants for treatment of members with refractory primary open‑angle glaucoma when first-line and second-line drugs have failed to control IOP. (Examples listed in policy: Ahmed glaucoma implant; Baerveldt seton; Ex‑PRESS mini glaucoma shunt; Glaucoma pressure regulator; Krupin‑Denver valve implant; Molteno implant; Schocket shunt.)
- Ab interno Kahook Dual Blade trabeculectomy — described as used for primary congenital glaucoma in case reports (Harvey and Schmitz 2020) and discussed as a minimally invasive technique.
5 Active Policies
N/A — N/A
JJ Part B
PALMETTO-L38792 — Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®)
JJ Part B
PALMETTO-N/A — N/A
JJ Part B
AETNA-CPB-0484 — Glaucoma Surgery
A56869 — Billing and Coding: Use of Laterality Modifiers
Related Codes
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