Summary & Overview
CPT 66160: Glaucoma Fistula with Sclera and Iris Excision
CPT code 66160 denotes a glaucoma surgery involving creation of a fistula with partial excision of the sclera and iris to reduce intraocular pressure. This procedure is a clinically significant intervention for patients with refractory or advanced glaucoma where medical therapy or less invasive procedures are insufficient. Nationally, surgical glaucoma codes like 66160 are important for access to specialty ophthalmic care and for shaping payment and utilization patterns across inpatient and outpatient surgical settings. Key payers in consideration include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, and the scope of services captured by this code. The publication also provides benchmarking metrics, payer coverage considerations, and relevant policy developments affecting reimbursement and prior authorization for surgical glaucoma care. The content is aimed at helping coding professionals, billing analysts, and policy stakeholders understand how CPT code 66160 maps to clinical practice and payer administration at a national level. Data not available in the input is noted where necessary.
Billing Code Overview
CPT code 66160 describes a surgical procedure for glaucoma in which the provider creates a fistula and excises portions of the sclera and iris to lower intraocular pressure. This procedure is an ophthalmic surgical intervention intended to establish an alternate aqueous outflow pathway to relieve elevated intraocular pressure associated with glaucoma.
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Service type: Surgical ophthalmology procedure
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Typical site of service: Hospital operating room or ambulatory surgical center
Clinical & Coding Specifications
Clinical Context
A typical patient is a 68-year-old with medically uncontrolled primary open-angle glaucoma presenting with progressive visual field loss and elevated intraocular pressure despite maximum tolerated topical and/or oral therapy. The patient reports worsening vision and optic nerve cupping on ophthalmic exam. After preoperative evaluation including visual acuity, slit-lamp exam, gonioscopy, pachymetry, and optic nerve imaging, the surgeon schedules a surgical intervention to create an external drainage fistula with partial sclerectomy and peripheral iridectomy to lower intraocular pressure.
The clinical workflow includes preoperative counseling and informed consent, preop clearance and topical or local anesthesia with monitored sedation, sterile prep and draping in an ambulatory surgery center or hospital operating room, creation of a conjunctival peritomy, partial-thickness scleral flap and excision of deep sclera with formation of an external fistula and iridectomy, intraoperative assessment of aqueous egress, closure of scleral flap and conjunctiva, and postoperative antibiotics and corticosteroid regimen. Postoperative visits include day 1, week 1, and monthly follow-ups to monitor intraocular pressure, wound integrity, visual acuity, and to manage complications such as hypotony, shallow anterior chamber, hyphema, or infection. Typical site of service is an ambulatory surgery center or hospital outpatient operating room. Service type is ophthalmologic surgical procedure for glaucoma drainage (external fistulizing surgery).
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |