Optometry Coding & Billing Alert

Medical necessity is a must for optimal payment

Make sure you know the definition of  "high-risk patients" to determine who is eligible for Medicare coverage for glaucoma screenings. This group includes those people with a family history of glaucoma, those with diabetes mellitus, and blacks age 50 and over.
 
If your patient is ineligible and you bill Medicare as though the patient were, this would be billing for a noncovered service as if covered, which is fraud.
 
Since Jan. 1, 2002, Medicare has reimbursed practices for screening for anyone at high risk for the disease. The service must be supervised or furnished by an optometrist or ophthalmologist who is legally authorized to perform such services in the state where the services are furnished.
 
Optometrists initially welcomed Medicare's decision to cover glaucoma screening, but using the 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 measurement, a test for visual acuity, and direct ophthalmoscopy or a slit-lamp biomicroscopic exam.
 
Codes G0117 and G0118 are bundled into E/M services 99201-99215, 99241-99245, 99301-99303, 99311-99313, 99315-99316, 99321-99323, 99331-99333, 99341-99345, 99347-99350 (all with a modifier indicator of 1) and eye exam codes 92002-92014 (all with a 0 modifier) because the fee for glaucoma screening includes the exam.
 
Medicare also bundles the following codes into 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.
 
The unadjusted reimbursement for G0117 is about $24.95 when it's performed in the office.

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 glaucoma screening.

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 say, "Yes, Medicare now offers a glaucoma screening benefit," and 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.
 
If the patient qualifies, schedule the examination. If the patient doesn't qualify, the examination would be considered routine eye care not covered by Medicare, and payment would be the patient's responsibility.
 
Any patient age 65 or over with a family history of glaucoma or with diabetes is probably already under the care of a physician 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 also have a disability such as end-stage renal disease (ESRD) with a history of diabetes and resulting 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. 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 optometrist performs the glaucoma screening and a complete examination because of the vision complaint. Bilateral nuclear sclerotis 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 report G0117.
 
If the patient is taking medication for glaucoma, and has no complaints, the physician performs a simple pressure check. If the doctor finds that the medication is working and that the pressure is normal, 99212 is probably the most appropriate code.
 
The physician probably sees the patient two or three times a year to make sure the medication is working and may alternate the glaucoma diagnosis system (92135, Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) and visual fields (92081-92083) at these visits, which are billable with 99212 (no modifier is needed on the E/M).
 
"They [visual fields] are billable approximately every six months depending on the type of insurance," and they require interpretation and report, says Nicola DuHamel, administrator for the Bascom Palmer Eye Institute of the Palm Beaches in Florida. And remember, 92135 is considered inherently unilateral, says Danielle Smith, CPC, coding specialist with Maine Eye Care Associates in Waterville. In other words, the fee allotted for 92135 only accounts for what is involved in performing the scanning done in one eye.
 
An eye examination code (92012) wouldn't be appropriate because this code "describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem," according to the CPT introduction to ophthalmology.