Coding Ahead
CasePilot
Medical Coding Assistant
CaseConsultant
Instant Email Coding Consultant
Case2Code
Search and Code Lookup Tool
CareerCenter
Medical Coding Job Board
Log in Register free account

Need help choosing the right code?

Ask CasePilot about procedures, modifiers, bundling, and coding guidance.

Try CasePilot

Official Description

Goniotomy

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 65820 refers to a goniotomy, which is a surgical intervention primarily aimed at treating congenital glaucoma in pediatric patients. Congenital glaucoma is a condition characterized by an abnormal increase in intraocular pressure due to developmental issues affecting the eye's drainage system. Specifically, this condition can lead to developmental arrest of the iris and ciliary body, which obstructs the trabecular network. This obstruction hinders the proper drainage of aqueous humor, resulting in elevated intraocular pressure that can damage the optic nerve and impair vision. During a goniotomy, the physician employs a series of precise steps to create an opening in the trabecular meshwork, thereby facilitating improved drainage of aqueous fluid. The procedure involves the administration of mitotic eye drops to constrict the pupil, stabilization of the eye, puncturing of the cornea, and the introduction of a viscoelastic tube to assist in fluid management. The use of a gonioscopy lens allows for direct visualization of the anterior trabecular meshwork, which is then incised to restore normal fluid dynamics within the eye. This surgical approach is critical for preventing further complications associated with congenital glaucoma and preserving the visual function of affected children.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The goniotomy procedure, as described by CPT® Code 65820, is indicated for the treatment of congenital glaucoma in children. This condition is characterized by increased intraocular pressure due to developmental abnormalities in the eye's drainage system. The following are specific indications for performing a goniotomy:

  • Congenital Glaucoma The primary indication for a goniotomy is the presence of congenital glaucoma, which can lead to significant ocular complications if not addressed.
  • Increased Intraocular Pressure The procedure is indicated when there is a documented increase in intraocular pressure that poses a risk to the child's vision and overall eye health.
  • Developmental Arrest of the Iris and Ciliary Body The presence of developmental issues affecting the iris and ciliary body that contribute to the obstruction of the trabecular network is a key factor in determining the need for this surgical intervention.

2. Procedure

The goniotomy procedure involves several critical steps to effectively treat congenital glaucoma. Each step is designed to ensure the successful incising of the anterior trabecular meshwork and restoration of normal aqueous fluid drainage.

  • Step 1: Administration of Mitotic Eye Drops The procedure begins with the administration of mitotic eye drops to the patient. These drops are used to constrict the pupil, which is essential for gaining access to the anterior chamber of the eye during the surgical intervention.
  • Step 2: Stabilization of the Eye Following the administration of the eye drops, the physician stabilizes the eye using forceps or sutures. This stabilization is crucial to maintain the position of the eye throughout the procedure and to ensure precision during the incision of the trabecular meshwork.
  • Step 3: Corneal Puncture The next step involves puncturing the cornea to create an entry point into the anterior chamber. This step is performed with careful attention to avoid damage to surrounding structures.
  • Step 4: Introduction of Viscoelastic Tube A viscoelastic tube is then placed into the anterior chamber through the corneal puncture. This tube serves to introduce fluid into the chamber, facilitating the surgical process and maintaining the space needed for the subsequent steps.
  • Step 5: Placement of Gonioscopy Lens A gonioscopy lens is placed on the eye to provide the surgeon with a clear view of the anterior trabecular meshwork. This visualization is critical for accurately identifying the area to be incised.
  • Step 6: Incision of Anterior Trabecular Meshwork Using a needle or knife blade, the physician incises the anterior trabecular meshwork. This incision is the key component of the goniotomy, as it allows for improved drainage of aqueous fluid from the eye.
  • Step 7: Removal of Tubing and Injection of Sterile Saline After the incision is made, the viscoelastic tubing is removed, and sterile saline is injected into the anterior chamber. This step helps to ensure that the chamber is properly filled and maintains its structure.
  • Step 8: Closure of Corneal Puncture Site Finally, the corneal puncture site is closed, completing the procedure. This closure is essential to prevent any potential complications and to promote healing.

3. Post-Procedure

Post-procedure care following a goniotomy is crucial for ensuring optimal recovery and monitoring for any complications. Patients may be observed for any immediate postoperative issues, such as bleeding or infection. It is important to follow up with the physician for regular assessments of intraocular pressure and overall eye health. Patients may also be prescribed topical medications, including anti-inflammatory or antibiotic eye drops, to aid in the healing process and prevent infection. The expected recovery time can vary, but close monitoring is essential to ensure that the surgical intervention effectively alleviates the symptoms of congenital glaucoma and that the child's vision is preserved.

Short Descr GONIOTOMY
Medium Descr GONIOTOMY
Long Descr Goniotomy
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 1
CCS Clinical Classification 14 - Glaucoma procedures

This is a primary code that can be used with these additional add-on codes.

66990 Addon Code MPFS Status: Active Code APC N ASC N1 CPT Assistant Article Use of ophthalmic endoscope (List separately in addition to code for primary procedure)
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
SG Ambulatory surgical center (asc) facility service
55 Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
GC This service has been performed in part by a resident under the direction of a teaching physician
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
73 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GW Service not related to the hospice patient's terminal condition
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
X3 Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2025-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"