Ophthalmology and Optometry Coding Alert

Question: Our office sometimes performs glaucoma screenings for patients who don’t meet Medicare’s definition of “high risk.” How should we code to be reimbursed for this service?

Alabama Subscriber

Answer: You should have the patient sign an advance beneficiary notice (ABN) and submit a claim of G0117-GA (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist; Waiver of liability statement issued as required by payer policy, individual case). Medicare will then deny the claim and send an explanation of benefits (EOB) to the patient, explaining that they are not considered at high risk for glaucoma.

Medicare covers glaucoma screenings for high-risk patients, but in some cases, 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 eye care provider recommends, and you know Medicare will not reimburse for a given service, you’d better use modifier GA and reach for an ABN.

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 or ophthalmologist 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. This screening service is limited to once per year per patient, and it includes a dilated exam with IOP test and either direct ophthalmoscopy or a slit lamp biomicroscopic exam. No other services may be billed on that day and the only billable diagnosis code is Z13.5 (Encounter for screening for eye and ear disorders).

Rule: After you’ve secured a signed ABN from a Medicare patient, you must inform Medicare that you have this information by appending modifier GA to the appropriate CPT^® code on the CMS-1500 form.

When Medicare sees the GA modifier and denies payment for the service, your MAC will send an EOB to the patient confirming that they are responsible for payment. If you fail to append the modifier, Medicare may not inform the patient of their responsibility.