Ophthalmology and Optometry Coding Alert

Ophthalmologists initially welcomed Medicare's decision to cover glaucoma screening effective Jan. 1, 2002. However, using these codes requires understanding the limitations of G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) and G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist).
 
Codes G0117 and G0118 include a dilated examination (DE), intraocular pressure measurement, a test for visual acuity, and direct ophthalmoscopy or a slit-lamp biomicroscopic exam, says Ann Rose, president of Rose and Associates, an ophthalmology coding and compliance consultancy based in Duncanville, Texas.
 
The Correct Coding Initiative (CCI, Version 8.0) bundles G0117 and G0118 with E/M services (99201-99215, 99241-99245, 99301-99303, 99311-99313, 99315-99316, 99321-99323, 99331-99333, 99341-99345, 99347-99350, all with a modifier indicator of 1) and eye exam codes (92002-92014, all with a 0 modifier) because the glaucoma screening is valued to include the exam. The following codes are also bundled with glaucoma screening: 92100 (Serial tonometry [separate procedure] with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day [e.g., diurnal curve or medical treatment of acute elevation of intraocular pressure]), 92120 (Tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method), 92130 (Tonography with water provocation) and 92140 (Provocative tests for glaucoma, with interpretation and report, without tonography).
 
Medicare accepts only one diagnosis code, V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma), for G0117 and G0118.
 
The unadjusted reimbursement for G0117 is about $52.13 when performed in the office.

Because technicians are not qualified to perform the DE component, it is unlikely that G0118 will be used, Rose says. A physician must perform a dilated examination.""
 
Use G0118 with caution. Some payers suggest that G0118 violates state laws because only an optometrist or ophthalmologist is licensed by the state to perform a DE. Theoretically" however a physician could perform the DE and a technician could perform the rest of the screening but Rose says this is unlikely.

Who Is Covered

Only high-risk patients are eligible for this benefit: those with a family history of glaucoma those with diabetes mellitus and African-Americans over age 50. Before scheduling a Medicare patient for glaucoma screening make sure the patient is eligible; if not he or she will be responsible for the charge. If the patient is ineligible and the ophthalmologist bills Medicare as though the patient were this would be billing for a noncovered service as if covered which is fraud.
 
When patients call for an appointment for the "free" glaucoma screening (as with all Medicare services the patient must pay a 20 percent copayment) the front desk should say "Yes Medicare now offers a glaucoma screening benefit " and ask if the patient has a family history of glaucoma has diabetes mellitus or is African-American age 50 or over and covered by Medicare. If the patient qualifies schedule the examination. If the patient doesn't qualify the examination would be considered routine eye care which is not covered by Medicare and payment would be the patient's responsibility.
 
The requirements for qualifying for the benefit will limit its use greatly Rose says. Any patient age 65 or over with a family history of glaucoma or with diabetes is probably already under the care of an ophthalmologist or optometrist who conducts regular glaucoma screening as part of general eye care using eye or E/M codes. Although Medicare extends this benefit to African-Americans who are age 50 and over this patient will probably have a disability such as end-stage renal disease (ESRD) with a history of diabetes and eye manifestations Rose says. "That's why even G0117 has very limited use for ophthalmologists."

If a patient comes in for a glaucoma screening and the physician discovers another problem an examination cannot be billed separately. "You can bill G0117 or you can bill a regular eye examination " Rose says "not both."
 
For example a 66-year-old new patient comes in for a glaucoma screening due to a family history of the condition. The technician in taking the history finds that the man has also been having problems driving at night because of headlight glare. The ophthalmologist performs the glaucoma screening and a complete examination because of the vision complaint. Bilateral nuclear sclerotis cataracts are discovered. Report the visit with the appropriate E/M (99201-99205) or eye code (92002-92004) with 366.16 (Senile cataract; nuclear sclerosis). Do not bill G0117.
 
In a related example an ophthalmologist sees a new Medicare patient for a glaucoma screening because the patient has a family history of the condition. The history reveals no problems. However the ophthalmologists detects cataracts during the slit-lamp portion of the exam. The doctor performs the glaucoma screening which was the purpose of the visit bills G0117 and asks the patient to return in several days for an evaluation for cataracts. When the patient returns report the appropriate E/M code or eye code as an established patient visit because the physician has already seen the patient face-to-face. 
  
While CCI will not allow G0117 or G0118 to be unbundled from eye exam codes it allows unbundling from E/M codes with modifier -59 (Distinct procedural service). If the patient came in for a medical problem the physician could perform glaucoma screening at this time as well billing G0117-59. However the medical problem and related examination would have to be unrelated to the glaucoma screening and documented as a different session encounter procedure site incision or injury for modifier -59 to apply says Raequell Duran president of Practice Solutions an ophthalmology coding and compliance consultancy based in Santa Barbara Calif. 
 
For example a 72-year-old woman comes in with red itchy eyelids. The ophthalmologist diagnoses allergic blepharitis (373.00 Blepharitis unspecified) and prescribes an ointment. The woman also requests a glaucoma screening. Code the visit with a lower-level E/M code (linked with 373.00) and G0117-59 (linked with V80.1).

If the patient comes in for a screening and the ophthalmologist finds indications of glaucoma or preglaucoma use V80.1 with G0117. For example if a patient comes in for a glaucoma screening and the physician finds elevated intraocular pressure (365.00 Borderline glaucoma [glaucoma suspect]; preglaucoma unspecified) report V80.1 with G0117. Do not use 365.00. "You can't bill for G0117 based on the finding of the exam " Rose says. "It's a screening exam."
 
Tonometry if performed the same day as the screening examination is not billable separately from G0117 or G0118 due to CCI bundles. If however the ophthalmologist has the patient in the previous example return several days later for serial tonometry (92100) for example that would be billable. On the day the tonometry is performed report the glaucoma (365.xx) with the office visit Duran says.
 
Visual fields (92081-92083) are not bundled with the glaucoma screen. For example the ophthalmologist performs a glaucoma screening on a patient and finds cupping. The technician performs a visual field test after the examination. For that day bill G0117 linked with V80.1 and 9208x linked with 365.00 Rose says.