Optometry Coding & Billing Alert

Published on Wed Jul 25, 2012 PDF

Medicare and most commercial insurances cover annual glaucoma screenings for high-risk individuals. These include:

• patients with diabetes
• individuals with a family history of glaucoma
• Hispanics 65 and older
• African-Americans 50 and older.

While these are the groups that the Medicare glaucoma screening codes G0117 and G0118 are targeting, most but not all of this group will probably have other ocular complaints or problems that will justify a complete exam which will include all the components of a glaucoma screening exam.

"Medicare criteria is specific when it comes to the specific circumstances for coverage of the glaucoma screening G codes and documentation would need to be supportive of screening policies when reporting these codes," warns Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y. "Patients with co-morbidities will typically require a more comprehensive evaluation and the service will be more than just glaucoma screening, hence resulting in an E/M or eye code for reporting."

Example: A patient with diabetes will most likely be under-going a full ophthalmic exam to determine the presence of any diabetic retinopathy or other disorders, including glaucoma. These encounters would be considered medically necessary E/M exams and submitted with the appropriate diabetes ICD9 code (such as 250.0x, Diabetes mellitus without mention of complication). "Although eye codes may be assigned instead of E/M codes, my personal recommendation is to used E/M codes when a patient presents with pathology and only assign eye codes for patients without chronic diseases or illnesses," says Mac.

Tip: Visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/glaucoma.pdf to read more on Medicare's glaucoma screening guidance.