Ophthalmology and Optometry Coding Alert

Not sure who qualifies for the screening codes? Find out here.

Your eye care practice is sure to see patients presenting for glaucoma screenings every week, but coding these services can be more complicated than simply applying a CPT® code to the service and moving on. Medicare and other payers have very strict rules when it comes to glaucoma screenings, and failing to adhere to those regulations can cause delayed - and even denied - payments. Read on for solid tips straight from Medicare representatives.

How Do I Code Screenings?

A glaucoma screening includes a dilated eye examination with intraocular pressure measurements and a direct ophthalmoscopy exam or slit-lamp bio microscopic examination, said NGS Medicare's Arlene Dunphy, CPC, during the payer's Aug. 30 webinar, "Glaucoma Screening and Preventive Services."

Medicare and most commercial insurers cover annual screenings for those determined to be at high risk. High risk patients are usually classified using the following criteria, Dunphy said:

• Those with diabetes
• Patients with a family history of glaucoma
• African-Americans aged 50 and older
• Hispanics aged 65 and above

Look to G0117 and G0118 for Medicare Patients

When you perform a glaucoma screening on a high-risk Medicare patient, you'll report either G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) or G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist), Dunphy said. In addition, she advises reporting ICD-10 code Z13.5 (Encounter for screening for eye and ear disorders) as the diagnosis code to use for a glaucoma screening.

The difference between G0117 and G0118 is that the physician performs the service described by G0117, while the physician supervises another clinical staff member in the code described by G0118. To qualify for G0118, the services must be furnished under the direct supervision of an ophthalmologist or optometrist. Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Often this is performed by a tech, but keep in mind that state laws dictate who can legally perform glaucoma screenings in each state.

Bottom line:  If the doctor is out to lunch, on vacation, out sick, or otherwise not available in the office suite, you cannot report a service as if it was furnished under the doctor's direct supervision.

Keep in mind that these codes can only be billed once a year. "Eleven full months must have passed since you performed the last screening before you can bill these codes again," Dunphy said.

The Correct Coding Initiative (CCI) bundles the glaucoma screening codes into both the E/M codes and the eye codes. Therefore, if the physician sees the patient for an eye exam and performs the glaucoma screening during that visit, you'll report the E/M code or the eye code, but not the screening.

"Again, this is a screening," says Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology in Canandaigua, New York. "Many patients who have already been diagnosed with normal tension glaucoma, open angle glaucoma, etc., are requesting this service. However, these patients do not qualify for the glaucoma screening service. Once a glaucoma diagnosis has been indicated, the screening is redundant."

Dollars and Cents: The reason you'd choose the appropriate eye care or E/M code instead of the glaucoma screening code when both are performed together is because the screening codes pay less than the exam codes. Whereas G0117 pays $55 and G0118 pays $43 based on Medicare guidelines, you'd collect about $86 when you report 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) and you'd get about $74 if you report 99213 (Office or other outpatient visit for the evaluation and management of an established patient...).

In addition, don't forget that deductibles and coinsurance payments do apply to glaucoma screenings, Dunphy said. This is different than some other screenings under Medicare, which waive these charges.

Avoid These Common Denial Reasons

The two main denial reasons for glaucoma screenings are that the patient has already reached his benefit maximum for the time period, and that the patient isn't considered high-risk, and is therefore not covered, Dunphy said. Therefore, you should ensure that the patient is in one of the high-risk groups before billing, and double-check that the screening meets the description of the codes. The clinician performing the service must also add a legible signature to the note, along with her credentials, Dunphy added.

CMS offers an online resource for practices that need further guidance on glaucoma screenings, said NGS' Michele Poulos during the call. To check out the Medicare page, visit https://www.medicare.gov/coverage/glaucoma-tests.html.