Ophthalmology and Optometry Coding Alert

Question: Our office manager thinks we can only perform glaucoma services on patients who have symptoms. Is this accurate? If not, can you help explain some of the glaucoma screening rules so we can educate our staff?

Codify Subscriber

Answer: Patients need not be symptomatic for Medicare to reimburse you for their screening services – hence the word "screening." In reality, certain groups are at higher risk for developing glaucoma, with risk factors being age, race, family history and medical history. CMS considers glaucoma screening reasonable and necessary for the early detection or prevention of the illness or disability and is appropriate for certain Medicare beneficiaries or individuals.

Effective Jan. 1, 2002, certain eligible beneficiaries with no complaints or prior history are covered for the screening if they meet any of the following conditions: Diabetes mellitus, a family history of glaucoma, African-Americans age 50 and older, or Hispanic-Americans age 65 and over.

Screening components must include both a dilated eye exam with intraocular pressure measurements and either a direct ophthalmoscopic examination or a slit-lamp bio microscopic examination.

To qualify for the glaucoma screening, the services must be furnished by an optometrist or an ophthalmologist, or furnished under the direct supervision of an ophthalmologist or optometrist. Make sure you're using the appropriate code depending on who performs the screening, either G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) if the doctor does the screening or G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist) if it's under the direct supervision of the doctor.

Unfortunately, some coders see these codes and assume that they should list both codes on their claims. However, this constitutes incorrect coding. As for the diagnosis code, report Z13.5 (Encounter for screening for eye and ear disorders) for asymptomatic patients who are getting screened for glaucoma.