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. It is estimated that over 4 million Americans have glaucoma but only half of those know they have it.2
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. 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.
Coverage Information
Medicare provides coverage of 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 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, and
* Hispanic-Americans age 65 and over.
Coding and Diagnosis Information
Procedure Codes and Descriptors
Medicare providers must use the following Healthcare Common Procedure Coding System (HCPCS) codes listed here.
G0117 – Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
G0118 – Glaucoma screening for high risk patients furnished under the direct supervision of an optometrist or ophthalmologist
Diagnosis Requirements
The beneficiary must be a member of one of the high risk groups mentioned to receive a Medicare-covered glaucoma screening. Medicare providers bill for glaucoma screening using the screening (“V”) diagnosis code of V80.1 (Special Screening for Neurological, Eye, and Ear Disease, Glaucoma). For further guidance, contact your Medicare Contractor.
Reasons for Claim Denial
The following are examples of situations when Medicare may deny coverage of glaucoma screening services:
* The beneficiary received covered glaucoma screening services during the past year.
* The beneficiary is not a member of one of the high risk groups.
* Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.
