Understanding Medicare's Glaucoma Screening Benefit
By including glaucoma screening as a benefit, Medicare has taken a positive step toward early detection. Here are the details.
By Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., San Bernardino, Calif.

As you know, people over the age of 60 have an increased risk of developing glaucoma, and Medicare is the primary insurance carrier for most of these patients. However, at its inception in 1965, the Medicare program didn't include routine eye examinations as a benefit, so glaucoma screening services weren't covered. However, thanks to a legislative change that took effect on Jan. 1, 2002, Medicare now provides expanded coverage for certain patients at risk for glaucoma, taking a positive step toward early detection.

Defining the benefit

The Benefits Improvements and Protection Act of 2000 provides annual coverage for glaucoma screening for eligible patients with no ocular complaints or prior history of the disease. The benefit is available to Medicare beneficiaries who meet any of the following criteria:

• Have diabetes
• Have a family history of glaucoma
• Are African-American and age 50 and older.

As long as the patient isn't diagnosed with glaucoma, the screening can be repeated yearly: "Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed."

Untapped potential

With declining reimbursement in surgical services, it becomes more important to focus on time spent in the office. Most importantly, capturing new patients is a powerful way to maintain and grow a practice. This benefit can be likened to a key to open the door of significant potential for both doctors and patients.

Based on Medicare's BESS data for 1999, eyecare providers performed 24 million eye examinations on Medicare beneficiaries not covered by an HMO. In that year, 34.5 million people were receiving Medicare benefits, so at least 30% of them never had an eye exam under this program (when you consider that some patients received multiple eye exams). For the sake of argument, I'll use a conservative number of 11 million beneficiaries who didn't seek out eye care as the basis of determining the untapped potential.

According to the Glaucoma Research Foundation, glaucoma affects about 9% of all seniors, and the incidence of this disease increases with age. By this estimation, of the 11 million Medicare beneficiaries who don't have their eyes examined yearly, about 1 million have undiagnosed glaucoma. It's likely that the number is much larger because of my conservative assumptions.

If all of the eyecare providers in the United States joined together to fight the "sneak thief of sight," each doctor could gain at least 200 new patients!

As we all know, glaucoma is one of the leading causes of blindness in the world, and it's usually asymptomatic. Many doctors can share unfortunate stories of patients showing up for an initial eye examination with bean-pot cups and 10-degree fields and no idea of the impending danger. Herein lies the win-win for both the doctors and the Medicare beneficiaries. This is an opportunity to enhance your patient base and detect the disease in unknowing patients.

Exam and filing requirements

The screening examination must include two components:

1) A dilated exam with intraocular pressure (IOP) measurement

2) Either direct ophthalmoscopy or slit lamp biomicroscopy.

To bill for the examination, submit a claim with HCPCS code G0117 (Glaucoma screening for high risk patients furnished by a physician) with the ICD-9 code V80.1 (Special screening for neurological, eye, and ear diseases, glaucoma). The code for type of service is Q.

	The screening exam must include dilation, IOP measurement and either direct ophthalmoscopy or slit lamp biomicroscopy.

Payment particulars

The glaucoma screening visit code (G0117) is bundled with all other ophthalmic services provided on the same day. If you perform a diagnostic test (for example, visual field, 92083) for a patient on the same day as his glaucoma screening, the diagnostic test will be paid, and the G0117 will be denied. As a practical matter, you should schedule such tests for a subsequent visit.

This new benefit is not a free examination. The beneficiary pays some of the cost. The glaucoma screening benefit is listed in the Medicare Physician's Fee Schedule and is subject to deductibles and copayments.

The national allowable for G0117 before geographical indices are applied is $52.13. If you're not a participating provider, you have a limiting charge of 115% of the non-participating allowable, so the national unadjusted amount in 2002 is $56.95.

Traditional Medicare coverage

Patients often have many subjective complaints that justify an examination, and most Medicare beneficiaries develop more than one ailment concomitantly. The patient with a family history of glaucoma who also complains of decreased vision merits an examination under Medicare's traditional guidelines. Two diagnoses might be made at the conclusion of the visit (cataract and glaucoma, for example). An E/M code (992xx) or an ophthalmology code (92xxx) best describes this encounter rather than G0117. The claim should not list the glaucoma screening service. If it does, the glaucoma screening will be bundled with the concurrent office visit.

Conversely, if a patient has no visual complaint or prior personal history of glaucoma, but he does have a family history of glaucoma, then traditional Medicare coverage wouldn't apply, but the glaucoma screening service would.

Follow-up care

Glaucoma is a chronic disease that requires follow-up care. Medicare covers examinations for beneficiaries with a personal history of glaucoma or those who are glaucoma suspects, even when asymptomatic. The plan on the chart note for the glaucoma screening visit might read: "Return 1-2 weeks for glaucoma reevaluation and scanning laser test OU." The chief complaint on the follow-up visit would read: "Reevaluate glaucoma and SLO OU" as the reason for the visit.

Positive benefit

The new Medicare glaucoma screening benefit is a positive step toward early detection and treatment of this disease. In most cases, glaucoma can be controlled with medication or surgery, but treatment can't occur until a patient is diagnosed.

Will this new benefit dramatically change your glaucoma practice? At the very least, it may introduce new patients to your office who might otherwise have postponed an eye examination.