Get the Facts About Reporting Glaucoma Screening to Medicare

coding for glaucoma screening

Before you report glaucoma screenings to Medicare, go through this quick Q&A to be sure you’ve got all the bases covered. The Medicare Benefit Policy Manual, Chapter 15, Section 280.1, is your source for information about glaucoma screenings that you report to Medicare, and we’ve put together the major points for reporting to Part B right here.

Get started: These are the HCPCS codes that apply. You should report only one on the patient’s claim:

  • G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist)
  • G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist).

What Qualifies as High-Risk for Coverage?

Medicare provides annual coverage (defined below) for glaucoma screening for the following individuals:

  • Those with diabetes mellitus
  • Those with a family history of glaucoma
  • African-Americans age 50 and older
  • Hispanic-Americans age 65 and older.

The list above identifies categories of patients considered to be at high risk of glaucoma.

Who Can Perform the Glaucoma Screening?

Medicare limits which providers may perform a covered glaucoma screening examination. The exam must be “furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law,” the Medicare Benefit Policy Manual states.

Remember that direct supervision requires the supervising provider to be in the office suite and immediately available for assistance or direction during the procedure. The supervising provider doesn’t need to be in the room, though. You can find definitions of supervision in the Medicare Benefit Policy Manual, Chapter 15, Section 80.

What Does the Glaucoma Screening Include?

The manual states the glaucoma screening must include these elements:

  • A dilated eye examination with an intraocular pressure measurement
  • A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.

How Often Can Patients Have Screenings?

We’ve already said Medicare provides annual coverage of glaucoma screening, but counting a year for Medicare can be tricky. The manual goes on to explain that “Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed.”

Which Diagnosis Code Is Appropriate?

The manual states only that claims require a screening diagnosis code. But you can expect payers and experts to point you to Z13.5 (Encounter for screening for eye and ear disorders). For instance, Palmetto Railroad Medicare shows Z13.5 as the appropriate code to report with G0117 and G0118.

The manual does not mention this, but, if available, you may opt to report a secondary code that shows the patient falls into a high-risk category, such as E11.- (Type 2 diabetes mellitus) or Z83.511 (Family history of glaucoma).

What About Payment?

The fourth quarter Medicare Physician Fee Schedule (MPFS) lists a rate of roughly $56.94 for G0117 and $42.53 for G0118.

But one thing you need to know about these glaucoma screenings under Part B is that deductible and coinsurance apply. Patients may be accustomed to free preventive services, so having the scheduling staff alert the patient to payment requirements can help avoid surprises.

Can You Report Screening Plus E/M?

Before you report screening code G0117 or G0118, check to be sure you aren’t reporting another service that Medicare bundles the screening into. For instance, Medicare practitioner Correct Coding Initiative (CCI) edits bundle G0117 and G0118 into 99213 (Office or other outpatient visit …). Another example is that Medicare bundles the glaucoma screening codes into 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits).

Bottom line: Expect to include glaucoma screening in E/M and general ophthalmology service codes. The smart move is to check CCI edits before you report G0117 or G0118 on the same claim as another CPT® or HCPCS Level II code.

What About You?

Do you report glaucoma screenings? Do you often report them separately, or does your practice generally perform these screenings on the same day that you report an E/M or general eye exam code?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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