Glaucoma represents a family of diseases commonly associated with optic nerve damage and visual field changes (a narrowing of the eyes’ usual scope of vision). It is the second leading cause of irreversible blindness in the United States.1 Of the various forms of glaucoma (such as congenital, angle-closure, and secondary), open-angle glaucoma is the most common
Over 2.2 million Americans age 40 and over have open-angle glaucoma. Often progressing silently, it is estimated that up to one-half of Americans with glaucoma may not know they have the disease.
Glaucoma occurs when increased fluid pressure in the eye presses against the optic nerve, causing damage. The damage to optic nerve fibers can cause blind spots to develop. These blind spots usually go undetected until the optic nerve is significantly damaged. If the entire optic nerve is destroyed, blindness results.4 Since glaucoma progresses with little or no warning signs or symptoms, and vision loss from glaucoma is irreversible, it is very important that people at high risk for the disease receive an annual screening. Studies have shown that the early detection and treatment of glaucoma, before it causes major vision loss, is the best way to control the disease.
The glaucoma screening covered by Medicare includes:
• A dilated eye examination with an intraocular
pressure (IOP) measurement
AND
• A direct ophthalmoscopy examination or a slitlamp
biomicroscopic examination
Increased IOP is common with glaucoma. In the past, it was thought that an increased IOP measurement indicated glaucoma; however, 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 increased IOP, which makes the examination of the eye and optic nerve (along with the IOP measurement) a critical part of the glaucoma screening.
Risk Factors
Anyone can develop glaucoma. Some risk factors that may increase an individual’s chances of developing glaucoma include age, race, family history, and medical history. Medicare provides coverage of an annual glaucoma screening for beneficiaries in at least one of the following high risk groups:
• Individuals with diabetes mellitus
• Individuals with a family history of glaucoma
• African-Americans age 50 and over
• Hispanic-Americans age 65 and over
Because of the prevalence of glaucoma found in these groups, it is of special importance for these individuals to receive regular glaucoma screenings. According to the National Eye Institute (NEI), African-Americans between the ages of 45 – 64 are 15 times more likely to go blind from glaucoma than Caucasians from the same age group5 and the incidence of glaucoma increases with age. Adults with diabetes are nearly twice as likely to develop glaucoma as other adults, and the longer a person has had diabetes, the more likely he or she is to develop glaucoma.
Coverage information
Medicare coverage of glaucoma screening was implemented with the Benefits Improvement and Protection Act of 2000 (BIPA). This coverage took effect on January 1, 2002. Medicare provides coverage for an annual glaucoma screening (i.e., at least 11 months have passed following the month in which the last Medicare-covered glaucoma screening examination was performed) for eligible beneficiaries in at least one of the high risk groups .
Coverage of an annual glaucoma screening is provided as a Medicare Part B benefit. The coinsurance or copayment applies after the yearly Medicare Part B deductible has been met. 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. NOTE: Medicare does not provide coverage for routine eye refractions.
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.
