Effective January 1, 2002, Medicare will provide coverage for an annual glaucoma screening for eligible Medicare beneficiaries, such as those with diabetes mellitus or a family history of glaucoma and African Americans aged 50 and older.
In addition, beginning with dates of service on or after January 1, 2006, 42 CFR 410.23(a)(2),revised, the definition of an eligible beneficiary in a high-risk category is expanded to included:
Ø Hispanic-Americans age 65 and over
CONDITION OF COVERAGE
For coverage to be considered, the screening examination must be furnished by or under direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law.
Screening for glaucoma is defined to include
· A dilated eye examination with an intraocular pressure measurement; and
· A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.
In the past, it was thought that a high IOP measurement indicated glaucoma, and an IOP measurement using non-contact tonometry (more commonly known as the “air puff test”) alone was commonly used to diagnose glaucoma.
Health care professionals now know that glaucoma can be present with or without high IOP, which makes the examination of the eye and optic nerve (along with the IOP measurement) a critical part of the glaucoma screening.
APPLICABLE HCPCS CODES
Use the following HCPCS codes to bill for glaucoma screening:
G0117 Glaucoma screening for high-risk patients furnished by an optometrist or
Ophthalmologist
G0118 Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist or ophthalmologist
FREQUENCY LIMITATIONS
Coverage for glaucoma screenings is only provided on an annual basis. Therefore, at least 11 months must pass following the month in which the last covered glaucoma screening examination was performed. Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed. To determine the 11-month period, start your count beginning with the month after the month in which the previous covered screening procedure was performed.
DIAGNOSIS CODING REQUIREMENTS
Bill glaucoma screening using screening ICD-9 code V80.1 (Special Screening for Neurological, Eye and Ear Diseases, Glaucoma). Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.
PAYMENT/DEDUCTIBLE INFORMATION
Reimbursement for glaucoma screening will be made on the basis of the Medicare physician fee schedule. Deductible and coinsurance apply. Claims from physicians or other providers where assignment is not taken are subject to the Medicare limiting charge.
Medicare will pay for glaucoma screening examinations when they are furnished by or performed under the direct supervision in the office setting of an optometrist or ophthalmologist, legally authorized to perform the services under State law.
DOCUMENTATION
Medical record documentation must support that the beneficiary is a member of one of the high risk groups previously discussed. The documentation must also support that the appropriate screening (i.e., either a dilated eye examination with IOP measurement and a direct ophthalmoscopic examination or a slit-lamp biomicroscopic examination) was performed.
