Ophthalmology and Optometry Coding Alert

When your ophthalmologist performs a glaucoma screening for a Medicare patient, you'll need to use Medicare G codes and ICD-9 V codes to prove medical necessity on your claim or risk nonpayment.

Medicare will cover annual glaucoma screenings for patients meeting high-risk parameters. What's high risk? Patients with one or more of the following characteristics are eligible for a covered Medicare screening:

• individuals with diabetes mellitus;

• individuals with a family history of glaucoma;

• African-Americans age 50 and over

• Hispanic ��" Americans age 65 and older.

If a Medicare patient has one of these risk indicators, he can request a covered glaucoma screening. When you report these services, use one of the following codes:

• G0117 -- Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist

• G0118 -- Glaucoma screening for high-risk patient furnished under the direct supervision of an optometrist or ophthalmologist.

The difference? G0117 is for screening services provided by the ophthalmologist or optometrist; use G0118 if the ophthalmologist or optometrist supervises the services.

When you report G0117 or G0118, you should always use V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma) as your primary diagnosis. However, you should not end your search for diagnosis codes there. Coders should try to get as much information on the claim as possible to describe the encounter and the patient's condition.

You can accomplish this task by reporting diagnosis codes for conditions that put the patient at high risk for glaucoma. Using these ICD-9 codes as secondary diagnoses can be important to your claim's health because they further explain why the screening is so important.

Example: An established Medicare patient with controlled type II diabetes and a family history of glaucoma reports to the ophthalmologist for a screening. The patient's medical record confirms that he has never had a glaucoma screening before. The doctor provides the screening himself.

In this instance, the patient meets parameters for a covered screening. On the claim, report the following:

• G0117 for the screening

• V80.1 appended to G0117 to show why you are conducting the test

• 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) appended to G0117 for the patient's diabetes

• V19.0 (Family history of blindness or visual loss) appended to G0117 to represent the family history of glaucoma.

Remember: To bill G0118, the service must be furnished under direct supervision of an ophthalmologist or an optometrist and the provider (certified ophthalmic technician, etc.) must be legally authorized to perform the services under state law.

When state law allows glaucoma service (such as a glaucoma screening) to be provided by someone other than the physician, the service requires the supervising physician to be present and readily available in the office suite at the time the service is rendered, says Hugh Aaron, MHA, JD, CPC, CPC-H, senior adviser for HCPro.

If a Medicare patient requests a glaucoma screening but does not meet the parameters for coverage, remember to have the patient sign an advance beneficiary notice (ABN) before the screen.

Because the beneficiary did not meet the proper parameters, Medicare will consider the screening routine eye care and will not pay for it. With a signed ABN on file, you're allowed to bill the patient for whatever amount of the screening Medicare doesn't cover.

When you get a signed ABN, don't forget to attach modifier GA (Waiver of liability statement on file) to the screening code to show that you have an ABN on file, says Dena Rumisek, a biller in Grand Rapids, Mich.

Hidden trap: The glaucoma screening is not payable when performed and billed with other payable services under the physician fee schedule. The Correct Coding Initiative (CCI) bundles glaucoma screening codes with E/M codes and the eye codes, as well as other ophthalmic services. If the ophthalmologist performs glaucoma screening on the same date as he performs other billed services, CCI bundles the glaucoma screening into the physician services, and Medicare payers will not pay for it separately. It would be unusual for a Medicare patient to present for a glaucoma screening only and not receive any other services.