Coding and Reimbursement
The New Glaucoma Benefit
Here's how to get paid under Medicare's new coverage, which could be good for your patients and your practice.

BY SUZANNE L. CORCORAN, COE

Q: What is the new glaucoma screening benefit?

The Benefits Improvements and Protection Act of 2000 (BIPA) provides annual coverage for glaucoma screening of eligible Medicare beneficiaries, beginning with services provided on or after January 1, 2002. Eligible beneficiaries are patients who are at high risk for glaucoma, defined by Medicare as:

• people with diabetes
• people with a family history of glaucoma
• African-Americans age 50 or older.

Other high-risk categories may be added later.

BIPA allows for one screening exam per 12-month period. The exam must include a dilated exam with intraocular pressure (IOP) measurement, and either a direct ophthalmoscopy exam or a slit lamp biomicroscopic exam.

Only ophthalmologists and optometrists can be paid for glaucoma screening exams. As with all services in a medical practice, technicians may assist the doctor with part of the exam, but they can't provide the entire exam because they're not licensed to do so.

Q: How do we get paid for this service?

Medicare has assigned a new HCPCS code for the glaucoma screening exam: G0117 (glaucoma screening for high risk patients, furnished by a physician). They've also specified that these exams will only be paid with diagnosis code V80.1 (special screen for neurological, eye, and ear diseases, glaucoma). You should use V80.1 on all of these claims, regardless of whether glaucoma is diagnosed during the exam.

The national Medicare Physician Fee Schedule allowable amount for G0117 is $52.13. (This amount will be adjusted by local wage indices.) The usual Medicare co-payments and deductibles apply, and should be covered by supplemental insurance plans, just like other Medicare-covered services.

For non-participating physicians, the national limiting charge for this service is $56.95.

Q: What are the implications for my practice?

The Glaucoma Research Foundation estimates that 3 million Americans have glaucoma, and that only about half have been diagnosed. In 1999, ophthalmologists performed 19 million eye exams on Medicare beneficiaries not covered by an HMO; optometrists performed 5 million eye exams during the same period. In that year, there were 34.5 million Medicare beneficiaries, so at least 30% of them never had an eye exam under the Medicare program (when you consider that some patients received multiple eye exams).

Based on these figures, there are at least 1 million undiagnosed glaucoma patients in this underserved elderly population. This is an enormous pool of potential patients, and reaching out to this population has the potential to increase ophthalmologists' and optometrists' practices considerably.

Q: Why should I provide this service when reimbursement is so low?

Dismissing the new screening benefit for this reason may be short-sighted. Most of the patients who come for a screening exam won't have a regular eye doctor. Many of these people will have glaucoma (or glaucoma suspect) and can become regular patients of your practice. Some patients may have other ocular diseases that require further care. In short, this is a great opportunity for practice growth.

At the same time, offering this service could have a tremendous impact on public health in the United States. The new Medicare glaucoma screening benefit has the potential to save the eyesight of a million undiagnosed Medicare beneficiaries. It will also prompt many others to get an eye exam, perhaps for the first time. So offering this service stands to benefit both your practice and your country.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. Sue may be reached at (800)399-6565 or via email at scorcoran@corcoranccg.com.