Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist will occasionally perform glaucoma screenings for patients who are sort of on the line to meet Medicare’s definition of “high risk.” For instance, we recently saw a patient who thinks her father had glaucoma but her mother now has Alzheimer’s and can’t be sure. How should we code to be reimbursed for this service?

New Hampshire Subscriber

Answer: You should have the patient sign an advance beneficiary notice (ABN). Then, report G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) with modifier GA (Waiver of liability statement issued as required by payer policy, individual case) attached

Medicare covers glaucoma screenings for high-risk patients, but there will occasionally be cases where the doctor isn’t sure the patient will meet Medicare’s description of “high risk.” 

When your office performs a service — even a noncovered procedure like certain glaucoma screenings — you deserve payment for it. If you don’t want to get caught absorbing the cost of services that a patient requests or the optometrist recommends, and you know Medicare will not reimburse for a given service, you’d better use modifier GA and reach for an advance beneficiary notice.

Properly used, the modifier/ABN combination allows you to collect payment for the optometrist’s effort directly from the patient. 

The proper time to have the patient sign an ABN is before the optometrist performs the service or procedure that you don’t think the patient’s carrier will reimburse. In some circumstances, you may not know for certain if Medicare will cover the service. When in doubt, protect yourself and request that the patient sign an ABN.