Glaucoma Screenings and Medicare: 7 Must-Know Myths

Your eye care practice likely reports glaucoma screenings so frequently that your coders no longer feel the need to look up the rules on how to bill the services to Medicare. However, the screening regulations are so vast and the rules change so frequently that your back office staff may be falling victim to common myths—with big consequences.

Miscoded claims lead to denials that bog down your revenue cycle, reducing cash flow and eating up staff time. But that’s not the only problem you’ll face—ultimate responsibility for coding errors lies with the physician, not the coder. So if an audit turns up a pattern of submitting erroneous claims, you won’t be able to plead ignorance.

To ensure that your glaucoma screening claims pass muster with CMS, check out the following commonly-held myths, along with the realities straight from NGS Medicare, which shared the correct way to bill for these services during its webinar, “Medicare Preventive Services: Glaucoma Screening Services and Preventive Services Resources.”

Myth 1: You Need Symptoms to Qualify for Glaucoma Screening

You may think patients only qualify for Medicare-reimbursed glaucoma screening services if they have symptoms. In reality, certain groups are at higher risk for developing glaucoma, said NGS’s Arlene Dunphy, CPC, during the webinar. Effective Jan. 1, 2002, certain eligible beneficiaries with no complaints or prior history are covered for the screening if they meet any one of the following conditions:

  • The patient has diabetes mellitus
  • The patient has a family history of glaucoma
  • The patient is African-American and aged 50+
  • The patient is Hispanic-Americans and aged 65+

Myth 2: Direct Supervision Involves Being in the Same City

To qualify for Medicare reimbursement, glaucoma screening services must be furnished by an optometrist or an ophthalmologist, or furnished under their direct supervision, Dunphy said. “Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.”

Bottom line: If you are out to lunch, on vacation, out sick, or otherwise unavailable, your coders cannot report the screening as if it was furnished under your direct supervision.

Myth 3: You Should Report Two HCPCS Codes for Glaucoma Screenings

Make sure your coders choose the correct code according to who performs the screening:

  • Use G0117 for a screening furnished by an optometrist or ophthalmologist
  • Use G0118 for a screening furnished under the direct supervision of an optometrist or ophthalmologist

Unfortunately, some coders see these codes and assume that they should list both codes on their claims. However, this constitutes incorrect coding and the claim will be denied.

As for your diagnosis code, you’ll report the ICD-10 code Z13.5 (Encounter for screening for eye and ear disorders) for asymptomatic patients who are getting screened for glaucoma.

Myth 4: One Year Always Equals 365 Days

Although coders recognize that glaucoma screenings are an annual benefit, you don’t have to wait exactly 365 days from one screening to the next.

“Once the beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed, as long as the beneficiary is not diagnosed with glaucoma,” Dunphy said. “To determine the 11-month period, start counting the following months in which the last covered glaucoma screening was performed. If the patient got the screening in July, the count would start in August, and the patient would be allowed to have another screening in July.”

Myth 5: Patients Needn’t Pay Anything

Under the Affordable Care Act, you may have gotten accustomed to offering preventive services without having to collect a deductible and coinsurance, but that’s unfortunately not the case for glaucoma screenings. “For these services, which is unusual for preventive services — usually they are waived — but this service does have deductible and coinsurance apply even though they’re preventive services,” Dunphy said.

Your patients are also likely used to receiving preventative services free of charge, which makes this type of scenario ripe for miscommunication. When a patient schedules a glaucoma screening, ensure that your scheduling staff alerts him or her that you’ll need to collect their copay and deductible at the time of service.

Myth 6: Tack on E/M Codes

If you assume you should report an E/M visit along with your glaucoma screening codes, Medicare has a different idea. Codes G0117 and G0118 are always bundled into E/M services and are not separately payable. No modifier can separate the bundles.

Therefore, if you do perform a separate and distinct E/M visit with the glaucoma screening, ensure that you document the distinct visit as such. Your coders will report the E/M but not the glaucoma screening — that would be bundled into your payment for the E/M.

Myth 7: Documentation of Symptoms Is Enough

Even if you’ve followed the six steps above to the letter, you may still face a denial for your screening services. Common denial reasons would be if the minimum time has not elapsed since the performance of the last procedure (11 full months haven’t passed) or the beneficiary does not meet the coverage guidelines of being high-risk.

As with all Medicare services, make sure you document the appropriate information, including documentation that the beneficiary falls into one of the high risk categories, and that appropriate screening was performed (pressure measurement, dilation, etc). “And of course a legible signature of the person performing the service, with their credentials,” Dunphy said.

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