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New Grad ODs, Here is How to Code & Bill Glaucoma

how-to-code-and-bill-glaucoma

How many of you would say you see a moderate number of glaucoma suspects or glaucoma patients? How many of you can say you know how to code for glaucoma like a pro?

We will start with how to code for glaucoma based on the severity of the disease and then how to code for ancillary testing.

Glaucoma Staging Codes

Medicare put out staging codes for glaucoma on October 1st, 2011 and all the insurance carriers had to make that change starting January 1st, 2012. I did not remember learning about glaucoma staging codes while I was in school. When I looked into the codes, it was not hard to learn.

First step

First code the type of glaucoma based on the signs and symptoms of the patient.

Glaucoma suspect:

365.00 – Preglaucoma, unspecified

365.01 – Open angle glaucoma, low risk (1-2 risk factors)

365.02 – Anatomical narrow angle / Primary angle closure suspect

365.05 – Open angle glaucoma, high risk (> 3 risk factors)

365.06 – Primary angle closure without glaucoma damage

Glaucoma:

365.10 – Open-angle glaucoma, unspecified

365.11 – Primary open-angle glaucoma

365.12 – Low tension glaucoma

365.13 – Pigmentary glaucoma

365.20 – Primary angle-closure glaucoma, unspecified

365.23 – Chronic or primary angle-closure glaucoma (angle damage + ON damage)

365.31 – Steroid induced glaucoma

365.52 – Pseudoexfoliation glaucoma

365.62 – Glaucoma associated with ocular inflammation

365.63 – Glaucoma associated with vascular disorders

365.65 – Glaucoma associated with ocular trauma

Second step

Next we have to determine the severity of glaucoma in the worse eye. Depending on which source you look at (AOA, American Academy of Ophthalmology or CMS), the definition of severity is a bit different.

 

  Mild Moderate Severe
AOA Mild concentric narrowing or partial localized narrowing of neuroretinal rim, disc heme, c/d asymmetry, isolated paracentral scotomas, partial arcuate or nasal step, damage limited to one hemifield with fewer than 25% of points involved on VF testing and mean deviation less than -6dB Moderate concentric narrowing of the neuroretinal rim, increase in disc pallor, loss of neuroretinal rim in 1 quadrant or localized notch, partial or full arcuate scotoma in at least on a hemifield (damage may be both hemifields but fixation not involved), mean deviation between     -6dB and -12dB. Complete absence of the neuroretinal rim in at least 3 quadrants, bayonetting of vessels, markedly increased area of central disc pallor, advanced loss of VF in both hemifields, 5-10 degrees central island of vision, mean deviation worse than   -12dB
American Academy of Ophthalmology ON changes consistent with glaucoma but no VF abnormalities on any visual field test or abnormalities present only on short-wave-length automated perimetry or frequency doubling perimetry ON changes consistent with glaucoma and glaucomatous VF abnormalities in one hemifield and not within 5 degrees of fixation. ON changes consistent with glaucoma and glaucomatous VF abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least 1 hemifield.
CMS 1 or more of the following in the worst eye: IOP>22mm Hg, symmetric or vertical elongated cup enlargement with neural rim intact and C/D ratio >0.4, focal optic disc notch, optic disc heme or history of optic disc heme, nasal step or small paracentral or arcuate scotoma or mild constriction of VF 1 or more of the following in the worst eye: enlarged optic cup with neural rim remaining but sloped or pale and C/D ratio>0.5 but <0.9, focal notch with thinning of neural rim or definite glaucoma VF defect (arcuate/paracentral scotoma), nasal step, pencil wedge or constriction of isopters. 1 or more following in the worst eye: severe generalized constriction of isopters, absolute VF defects within 10 deg of fixation, severe generalized reduction of retinal sensitivity, loss of central visual acuity, diffuse enlargement of optic nerve cup (C/D ratio >0.8), wipeout of all or portion of the neural retinal rim.

Codes for staging glaucoma include 365.71 (mild glaucoma), 365.72 (moderate-stage glaucoma) and 365.73 (severe glaucoma). 365.74 is for indeterminate stage of glaucoma, which includes unreliable/uninterpretable visual; field testing, patient incapable of visual field testing or visual field not performed yet. You can go here for clinical examples related to staging, which is set up by American Academy of Ophthalmology.

Ancillary testing related to glaucoma

When I started seeing patients on my own, I did not know which tests could be done on the same day. Before we get into that, let’s cover some ancillary glaucoma tests. I have included approximately how much Medicare/CMS pays for each test in the parenthesis in my area.

Gonioscopy:

  • 92020 ($27.12)

Visual fields:

  • 92081 ($34.29) E.g. tangent screens, Autoplot, arc perimeter or single stimulus level automated test
  • 92082 ($49.20) E.g. at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test
  • 92083 ($65.03) E.g. Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry

Serial tonometry:

  • 92100 ($80.00) – Intraocular pressure (IOP) is checked at least three separate times in the course of a day with 3 or more IOP measurements. This procedure is usually done when someone is having an angle closure attack or if there is large fluctuation in IOP to determine or re-evaluate treatment options.

Pachymetry:

  • 76514 ($14.00) – For most insurances, this procedure is only billed once in a lifetime if a patient has glaucoma. With some diseases, it can be billed multiple times, which we will cover in a different article.

Fundus photos:

  • 92250 ($70.00)

Scanning ophthalmic computerized diagnostic imaging

  • 92133 ($44.37) – Optic Nerve Head Evaluation
  • 92134 ($45.34) – Retinal Evaluation

In order for any of the above tests to be billed to any insurance carriers, you must have interpretation and report. Depending on the insurance carriers, some of these tests can be repeated during either a calendar year or a year from the date of service (you would have to check with specific insurance regarding this). Most insurance carriers will allow one OCT for glaucoma suspect or mild glaucoma and two per year for moderate glaucoma. Per CMS, you can do either scanning ophthalmic computerized diagnostic imaging (OCT) or fundus photos per visit. For example, if you were to do fundus photos for today’s visit, you can do an OCT when the patient returns for a follow up.

Also, when a patient returns for ancillary testing or intraocular pressure check, you can bill an office visit (992xx codes) along with other tests.

If you have any questions regarding the article or coding in general, please let me know. I will try to answer them or refer you to a source who can help you.

References:

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About Bhumika Patel

I graduated in 2014 from University of MO, Saint Louis. I currently work at a private practice in Rock Hill, SC (30 minutes south of Charlotte).

2 comments

  1. Just an FYI, the code for moderate stage glaucoma is 365.72.

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