Ophthalmology and Optometry Coding Alert

Hint: Check the NCCI edits before you report these services along with an E/M code.

Glaucoma screenings are among the essential tools that eye care providers have in helping to prevent blindness, which makes these services a high priority for many practices. However, if you don’t know the coverage guidelines for screenings, you could face denials or requests for more information before you can collect for them.

To help improve your reimbursement odds, consider the following 10 tips provided by NGS Medicare’s Arlene Dunphy, CPC, during the Part B payer’s Sept. 3 webinar, “Preventive Services: Glaucoma Screening.”

Tip 1: Understand Who Can Perform the Service

“Glaucoma is the second most common cause of blindness in the United States, and affects about 2.7 million Americans,” Dunphy said. Since the condition often progresses silently with no symptoms, screenings are key to ensure that all cases are caught early so treatment can take place, she said. “CMS has determined that there’s enough evidence to conclude that screening for glaucoma is reasonable and necessary for the early detection and prevention of the illness.”

Glaucoma screening can be performed by or furnished under direct supervision of an optometrist or ophthalmologist. “Direct supervision, under the guidelines, means that a physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure,” she noted.

Tip 2: Correct Code Will Depend on Who Performed the Service

You’ll report G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) or G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist) for your glaucoma screenings, depending on who performs the service, Dunphy said.

The difference between G0117 and G0118 is that the physician performs the service described by G0117, while the physician supervises another clinical staff member in the service described by G0118. To qualify for G0118, the services must be furnished under the direct supervision of an ophthalmologist or optometrist. Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Often this is performed by a tech, but keep in mind that state laws dictate who can legally perform glaucoma screenings in each state.

Bottom line: If the doctor is out to lunch, on vacation, out sick, or otherwise not available in the office suite, you cannot report a service as if it was furnished under the doctor’s direct supervision.

Tip 3: Patients Must Have Specific Risk Factors

“While anyone can develop glaucoma, certain groups of people are at higher risk of developing this disease,” Dunphy said. The screening services that Medicare covers are only available to those high-risk patients. Risk factors typically include age, race, family history, and medical history.

Annual coverage is available for glaucoma screenings for certain eligible Medicare patients who are considered high risk, using the following criteria, Dunphy said:

• Those with diabetes mellitus
• Individuals with a family history of glaucoma
• African-Americans age 50 and over
• Hispanic-Americans age 65 and over

Tip 4: You Must Perform 2 Screening Componentsv

Although you can add other screening services during the glaucoma screenings, your documentation must at the very least include both of these components to collect from Medicare, Dunphy said:

• Dilated eye examination with an intraocular pressure measurement
• Direct ophthalmoscopy examination or a slit-lamp bio microscopic examination

Tip 5: Check NCCI Edits

“If you’re doing any other services on the same day as the glaucoma screening, ensure those services are not bundled,” Dunphy said.

For instance, the National Correct Coding Initiative (NCCI) bundles the glaucoma screening codes into both the E/M codes and the eye codes. Therefore, if the physician sees the patient for an eye exam and performs the glaucoma screening during that visit, you’ll report the E/M code or the eye code, but not the screening, since the screening pays a lower amount than the other codes.

Tip 6: Remember the Right Diagnosis Code

When it comes to diagnosis coding, you should use the ICD-10 code Z13.5 (Encounter for screening for eye and ear disorders) on your glaucoma screening claims. “Keep in mind that this is for the preventive glaucoma screening,” Dunphy said. “If your patient already has glaucoma, you will not report the screening services.”

Tip 7: Keep an Eye on the Calendar

You can perform a glaucoma screening on high-risk patients once every 12 months, and 11 full months must have passed since the last one, “as long as the beneficiary is not diagnosed with glaucoma,” Dunphy said. So if you have a screening in July, you can get another one the following July.

Tip 8: Cost-Sharing Applies

It’s important to keep in mind that patients are responsible for paying the deductible and coinsurance amounts for glaucoma screenings. “For most of the preventive services, the coinsurance and deductible are waived, but for this service it is not,” Dunphy said. “Deductible and coinsurance do apply to this service, CMS has not waived that for this service.”

Tip 9: Avoid These Common Pitfalls

Among the common reasons that Part B payers deny this service are that the patient is not classified as high risk, or the patient has already reached the maximum benefit for that particular time period, Dunphy said. “If the minimum time has not elapsed since the performance of the last procedure, you could face this type of denial,” she noted.

Tip 10: Shore Up Your Documentation

Don’t let your documentation slide when you perform glaucoma screenings. The medical record should include demonstration that the beneficiary falls into one of the high risk groups, and should also show that the appropriate screening procedure was performed.

“Make sure you also have a legible signature of the person who performed the service, and their credentials,” Dunphy said. “Remember that your documentation is always key to getting the services that you rendered paid for.”