Regrettably, this benefit remains unused by many eye care professionals, largely because they are familiar with but struggle with CPT codes. The benefit is described in the Healthcare Common Procedure Coding System (HCPCS) book, but I doubt most ophthalmologists even know where their HCPCS book can be found. This article explains the history and design of the Medicare Glaucoma Detection Benefit as well as how to use it in practice.
RATIONALE FOR THE BENEFIT
The reimbursement for a Medicare service is based on a patient's complaint. When someone presents with cloudy vision and the physician diagnoses a cataract, for example, the Medicare system covers the service and reimburses the physician for the visit. Unfortunately, in the US, most cases of glaucoma are open angle and without symptomatology. Before the Medicare Glaucoma Detection Act, physicians could certainly screen for the disease, but, if they found nothing and the patient did not have complaints, there was no code for ruling out glaucoma. Creative coding occasionally ensued, which was clearly an undesirable practice.
In 1997, Congress enacted the Benefits Improvement and Protection Act, a landmark bill covering preventive care (obviously to include screening for certain diseases). Congress decided to include mammography, Papanicolaou tests, vaccines, and colorectal cancer screening, but not glaucoma screenings.
The Federal Register, which establishes the rules for Medicare coverage, stated, “glaucoma tests are covered if they are medically necessary to evaluate a specific complaint or symptom that might indicate glaucoma or to monitor an existing medical condition.”1 The AAO Health Policy Committee seized that moment to address glaucoma screenings, and, fortunately, excess funds were available in the Medicare system due to physician cutbacks. The AAO assembled an expert panel of glaucoma specialists and epidemiologists to write a benefit centered on evidence-based medicine. I was the counselor for the American Glaucoma Society during the formulation and passage of this legislative act, and I, too, was determined that this bill should not falter.
The benefit was sponsored by key legislators Representative John Lewis (D-GA) and Representative Mark Foley (R-FL) but had to endure a long battle before coming to fruition. In December 2000, President Clinton signed the Medicare Glaucoma Detection Act, which changed the Federal Register to read: “to conform our regulations to statutory requirements of the Benefits Improvement and Protection Act, we are specifying an exception to the list of examples of routine physical checkups excluded from coverage … for glaucoma screening.”1 Ophthalmologists and optometrists who screened asymptomatic, high-risk Medicare beneficiaries for glaucoma were assured reimbursement for the service.
THE BENEFIT'S DESIGN
Typically, a glaucoma screening includes an IOP assessment. The American Glaucoma Society, AAO, and US Office of Technology Assessment did not consider IOP evaluations alone to be sufficient for screenings, however. The recommendation based on the consensus of the panel was that screenings comprise a brief history, an IOP measurement, a slit-lamp biomicroscopy examination, and a detailed dilated examination of the optic nerve. In an effort to limit costs, the panel decided that the typical glaucoma screening need not include fundus photos, visual field examinations, extended ophthalmoscopy, or disc scanning.
The Medicare Glaucoma Detection Benefit covers an annual examination by an ophthalmologist or optometrist for beneficiaries who are self-identified African Americans aged 50 years or older, who have a family history of glaucoma, or who have diabetes mellitus. The bill also specifies that the screening is bundled with E/M codes; eye codes 92002, 92004, 92012, and 92014; serial tonometry; tomography; and a water provocative test. These procedures are included with the benefit code and are therefore not billable. The HCPCS code for the screening itself is G0117. The ICD-9 diagnosis code is V80.1.
IN PRACTICE
Glaucoma afflicts at least 3 million Americans, and approximately half of them do not know they have the disease.2 It is the second leading cause of blindness in Medicare patients and the leading cause of blindness among African Americans. The cost of glaucoma care is a sizeable problem for the Medicare system. The costs associated with incisional glaucoma surgery are high, and the recovery is significant. Early diagnosis of the disease considerably improves a patient's prognosis and may reduce potential surgical costs.
I do not think the Medicare system has yet determined the optimal way to use the Medicare Glaucoma Detection Benefit, which is not surprising since it breaks new ground as a screening benefit. For physicians who wish to detect glaucoma early and thus most successfully inhibit its progression, however, this benefit could enable them to provide optimal care as well as employ a rewarding practice-builder.
Practitioners should educate their patients about glaucoma and screen for the disease at the same time. If the patient meets the aforementioned criteria, physicians may file for the benefit whether or not glaucomatous progression is detected during the screening. They may perform gonioscopy if necessary but should not bill for it at this time because it is bundled with the benefit. If glaucoma is detected, the physician should file for the benefit on that visit, schedule the patient for a follow-up, comprehensive examination, and initiate the appropriate tests during the follow-up.
Only by familiarizing themselves and their staff with this benefit and then employing it will practitioners determine the next best screening bill or how to improve the existing one.
Ronald L. Fellman, MD, is in private practice in Dallas. Dr. Fellman may be reached at (214) 360-0000; rfellman@aol.com.
1. "Screening for Glaucoma, Proposed Rule." Federal Register 66 (2 Aug. 2001): 40386-40388.
2. Quigley HA, Vitale S. Models of open-angle glaucoma prevalence and incidence in the United States. Invest Ophthalmol Viss Sci. 1997;38:83-91.
