Optometry Coding & Billing Alert

Published on Fri Nov 16, 2007 PDF

ABN is a must if patient is ineligible for covered test

When your optometrist performs a glaucoma screening for a Medicare patient, you-ll need to use Medicare G codes and ICD-9 V codes to prove medical necessity on your claim or risk nonpayment.

Use this primer to help you report glaucoma screenings for Medicare patients.

Medicare will cover annual glaucoma screenings for patients meeting high-risk parameters, says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore.

What's high risk? Patients with one or more of the following characteristics are eligible for a covered Medicare screening:

- Diabetes

- Family history of blindness/visual loss

- Blacks over age 50

- Hispanics 65 or older (Medicare added this category in 2006).

If a Medicare patient has one of these risk indicators, he can request a covered glaucoma screening. When you report these services, use one of the following codes:

- 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.

The difference? G0117 is for services the doctor provides; use G0118 if the optometrist supervises the services, Felthauser says.

When you report G0117 or G0118, you should always use V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma) as your primary diagnosis, says Alice Reybitz, RN, BA, CPC, CPC-H, a healthcare coding and billing consultant based in Belleair, Fla.

However, you should not end your search for diagnosis codes there, Reybitz says. "The V80.1 code is always required, but the coder is always charged with the responsibility of getting as much information on that claim as possible to eliminate the need for paper submission with lengthy reports," she says.

You can accomplish this task by reporting diagnosis codes for conditions that put the patient at high risk for glaucoma. Using these ICD-9 codes as secondary diagnoses can be important to your claim's health because they further explain why the screening is so important, Reybitz says.

Example: An established Medicare patient with controlled type II diabetes and a family history of visual loss reports to the optometrist for a screening.

The patient's medical record confirms that he has never had a glaucoma screening before. The doctor provides the screening herself.

In this instance, the patient meets parameters for a covered screening. On the claim, report the following:

- G0117 for the screening

- V80.1 appended to G0117 to show why you are conducting the test

- 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) appended to G0117 for the patient's diabetes

- V19.0 (Family history of blindness or visual loss) appended to G0117 to represent the family history of glaucoma.

Remember: To use G0117 or G0118, your optometrist must be certified to perform glaucoma screenings in your state.

If she is not certified, your optometrist cannot perform glaucoma screenings.

If a Medicare patient requests a glaucoma screening but does not meet the parameters for coverage, remember to have the patient sign an advance beneficiary notice (ABN) before the screen.

Because the beneficiary did not meet the proper parameters, Medicare will consider the screening routine eye care and will not pay for it. With a signed ABN on file, you-re allowed to bill the patient for whatever amount of the screening Medicare doesn't cover.

When you get a signed ABN, don't forget to attach modifier GA (Waiver of liability statement on file) to the screening code to show that you have an ABN on file.