Optometry Coding & Billing Alert

The patient must also already be a Medicare beneficiary, Sellers says.

If your patient is ineligible and you bill Medicare as though the patient were eligible, this would be billing for a noncovered service as if covered, which is fraud.

The patient "literally has to ask for the screening," Sellers says. 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.

Tip: 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 - and you need to communicate this possibility to the patients before scheduling the exam. If you're not sure whether the patient qualifies as high-risk, you can have the patient sign an advancebeneficiary notice (ABN) and submit the claim appended with modifier GA (Waiver of liability statement on file).

Example: A Medicare patient requests a glaucoma screening, but you're not sure the patient will meet Medicare's description of "high risk." You have the patient sign an ABN and submit a claim of G0117-GA. Medicare denies the claim and sends an EOB to the patient, explaining that he is not considered at high risk for glaucoma.

Any patient age 65 or over with a family history of glaucoma or with diabetes is probably already under the care of an optometrist who conducts regular glaucoma screening as part of general eye care, using eye or E/M codes.

Strike E/M Codes From Screening Claims

Providing glaucoma screenings means understanding other limitations of G0117 and G0118 (Glaucoma screening for high-risk patient furnished under the direct supervision of an optometrist or ophthalmologist). 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.

The unadjusted reimbursement for G0117 is about $45 when it's performed in the office. So why would you report it instead of an eye exam code, which might pay as high as $96? Without a specific medical complaint, Medicare will deny your eye code claim as routine.

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 dilated exam. Theoretically, however, an optometrist could perform the dilated exam and a technician could perform the rest of the glaucoma screening.

The National Correct Coding Initiative imposes other limitations. NCCI bundles codes G0117 and G0118 into:  

These bundles all have a modifier indicator of "0," meaning you may not report the codes separately under any circumstances.

NCCI also bundles glaucoma screening into the following diagnostic tests: 

Medicare accepts only one diagnosis code, V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma), for G0117 and G0118.

Address Other Problems Separately

"The glaucoma screening exam can only be billed if it is the only service given to the patient that day," says Regan Bode, CPC, OCS, clinic administrator at the Northwest Eye Clinic in Bellingham, Wash. "If a patient presents with any problems or complaints, bill the appropriate-level office visit for the complaint. The screen cannot be billed in addition to the complaint exam. If you find or diagnose glaucoma in a patient presenting for the screen, bill that visit as the screen, then future exams for treatment of your findings will be covered like normal."

Example: A 66-year-old new patient comes in for a glaucoma screening. The technician, in taking the history, finds that the man has also been experiencing some fading of colors and needs brighter light to read.

The optometrist performs the glaucoma screening and a complete examination because of the vision complaint. Bilateral nuclear sclerotic 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.