Ophthalmology and Optometry Coding Alert

Make sure you know the definition of  "high-risk patients" to determine who is eligible for Medicare coverage for glaucoma screenings.
 
Since Jan. 1, 2002, Medicare has reimbursed practices for screening those who meet the definition for being at high risk for the disease. This group includes those with a family history of glaucoma, those with diabetes mellitus, and blacks over age 50.
 
The screening service has to be furnished by or under the supervision of an optometrist or ophthalmologist who is legally authorized to perform such services in the state where the services are furnished.
 
Ophthalmologists initially welcomed Medicare's decision to cover glaucoma screening, but 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 (IOP) measurement, a test for visual acuity, and direct ophthalmoscopy or a slit-lamp biomicroscopic exam.
 
Codes G0117 and G0118 are bundled with E/M services 99201-99215, 99241-99245, 99301-99303, 99311-99313, 99315-99316, 99321-99323, 99331-99333, 99341-99345, 99347-99350 (all with an indicator of 1)  and eye exam codes 92002-92014 (all with a 0 indicator) because the glaucoma screening and an ophthalmic evaluation are not payable on the same day. 
 
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.
 
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 this is unlikely.

Who Is Covered?

 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 ask if the patient has a family history of glaucoma, has diabetes mellitus, or is black and age 50 or over and covered by Medicare.
 
Be sure to ask if the patient has both Part A and Part B coverage. Physician's services are paid under Part B.
 
If the patient falls into one of these risk groups, 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 is the patient's responsibility.
 
The person speaking to the patient should also verify whether or not the patient has a visual complaint other than his request for a glaucoma screening. The patient may be having a sign or symptom that he thinks is related to glaucoma.
 
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 blacks 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.

No Extra Services at Screening

If a patient comes in for a glaucoma screening and the physician discovers another problem, you cannot bill an examination separately if you want Medicare to pay for the screening.
 
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 sclerotic 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 screening reveals no problems. However, the ophthalmologist 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 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 been seen face-to-face.
 
While NCCI will not allow unbundling of G0117 or G0118, it allows you to unbundle 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, but check with your carrier first. However, the medical problem and related exam 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.
 
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).

Diagnosis Coding

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. When the patient returns for a follow-up visit of the "known condition" of glaucoma, apply the appropriate glaucoma diagnosis code.
 
Tonometry, if performed the same day as the screening examination, is not billable separately from G0117 or G0118 due to NCCI bundles. But if the ophthalmologist has the patient in the previous example return to the office several days later for a serial tonometry procedure (92100), that would be billable.
 
It could be that the physician prescribed the patient a drug during the initial encounter and wanted the patient to return to evaluate the effect of the medication during various times of the day. On the day the serial tonometry is performed, report the glaucoma diagnosis (365.xx) with the office visit and tonometry, says Raequell Duran, president of Practice Solutions in California.
 
Note: If the physician wants the patient to return for a follow-up visit and a single reading of intraocular pressure, code 92100, for serial tonometry, should not be indicated.
 
Visual fields (92081-92083) are not bundled with the glaucoma screening codes in the NCCI. Although in the initial language for the screening codes in the Federal Register it was stated that the services in the General Ophthalmological section would be included in the screening services, which would include all services in  the code range of 92002-92499, they are not included in the NCCI list.
 
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 with V80.1, and 9208x with 365.00.