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Breakdown of conventional outflow MIGS Dr. Singh described some of the many options in MIGS de- vices, including outflow stents, those that work by dilation of the outflow system, and trabecular meshwork stripping/ removal procedures. Dr. Singh highlighted cataract surgery and MIGS, noting that IOP reduction is not all from phaco. A microbypass stent effectively reduces IOP across different ranges of base- line IOP, and that's consistent with current literature that shows a greater reduction in eyes with higher baseline IOP. He said the goal is trying to protect from visual field progression. Loss of visual function in patients with glauco- ma can affect a number of things, including judging dis- tances, going out of the home, facial recognition, driving, reading, seeing at night, walking, and peripheral vision. As far as standalone procedures, Dr. Singh said they ha- ven't grown at the same rate as cataract surgery and MIGS, and this could be due to a perception that they are ineffec- tive or a fear of complications. The key to appreciating the success of MIGS is the effect on topical drop burden, he said. When you define success of surgery, it's not IOP reduc- tion, it's decreasing the drop burden as well. MIGS with and without cataract surgery have consistently demonstrated a decrease in drop burden. "My decision to pursue an intervention is so much eas- ier and clearer when someone is not on drops," he said. He said to pay attention to clues that a patient is not compliant. For example, if the patient is continually asking for samples, notes vision fluctuation, or can't remember the color of the drop, these may be signs of poor compliance. Studies show that a reduction of drops makes a difference in quality of life, Dr. Singh said. MIGS and drug delivery J codes Dr. Bedrood detailed some of the codes relating to MIGS and drug delivery. First, she discussed J7351, the code for Durysta, adding that this is a procedural pharmaceutical that treats open angle glaucoma up to ocular hypertension. It can be done in the physician clinic setting, ASC, or HOPD. With code J7351, you bill for 10 units. She also noted CPT code 66030, which is for injection in the anterior chamber of the eye. iDose TR is also a procedural pharmaceutical (not a MIGS) for the treatment of primary open angle glaucoma or ocular hypertension. There are three payments associated— the drug payment (J7355), the facility payment (0660T), and the professional payment (0660T). The thing to consid- er for this, she said, is it's Medicare Part B with supplemen- tal and secondary right now. Effective November 17, 2024, trabecular stents are covered for mild to moderate POAG in conjunction with cataract surgery. Standalone subconjunctival stents or tra- becular stents are covered for refractory glaucoma, defined as prior failure of a filtering/cilioablative procedure or uncontrolled IOP defined as progressive damage or mean diurnal IOP greater than or equal to 20 mm Hg on maximal- ly tolerated medical therapy. Phaco can be performed with a single MIGS procedure, and a combination of MIGS and an aqueous shunt is not covered. Phaco with combination of MIGS is not covered (for example, stent plus canaloplasty or goniotomy). The new policies do not address ECP, and coverage should be unchanged. Regarding phaco/ECP plus trabecular stent, there is guidance from AAO with three options: 1) Submit CPT 66999 unlisted procedure. 2) For the phaco/ stent, submit 66989/91 with modifier –22 increased pro- cedural service for the ECP. 3) For the phaco/ECP, submit 66987/8 and append modifier –22 for the stent. Dr. Radcliffe said he thinks the data is what drives the payers' decisions, and "we have a good ability to fight back." More data on any of these procedures and devices is good to see, he said, adding that data and studies can be company sponsored or from doctors pulling data together. © Copyright 2025 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the staff and leadership of EyeWorld and ASCRS and in no way imply endorsement by EyeWorld and ASCRS. Thank you to the sponsors of this program DIAMOND LEVEL PLATINUM LEVEL GOLD LEVEL

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