Coding for the care of glaucoma patients is relatively straightforward. The primary tests necessary to properly diagnose and manage glaucoma are gonioscopy, fundus photography, pachymetry, threshold visual field testing and posterior scanning laser glaucoma test (SLGT). In addition, serial tonometry, extended ophthalmoscopy and anterior scanning laser testing may also be indicated.

Gonioscopy and fundus photography are typically performed on a yearly basis, unless disease progression is noted. According to the AOAs Clinical Practice Guidelines, gonioscopy should be performed at least annually for all glaucoma patients and suspects. The frequency of fundus photography varies by Medicare carrier.

While extended ophthalmoscopy could be used in place of fundus photography, fundus photography is the more accepted standard of care.

Posterior SLGT and fundus photography cannot be billed on the same date of service, according to the Centers for Medicare & Medicaid Services (CMS). CMS classifies both of these diagnostic tests as imaging of the optic nerve, and considers them repetitive when performed together.

Pachymetry has become a standard test for all glaucoma suspects and patients. Many Medicare carriers limit this procedure to once per doctor or once per lifetime. If you cannot obtain the patients past medical records containing this information, repeat the pachymetry measurement.

Serial tonometry can be performed if a diurnal curve pattern for a particular patient is indicated. An Interpretation and Report (I&R) must be done for this procedure. It is not typically coded at the same time as evaluation and management (E&M) or ophthalmic visit codes.

Common Codes for Glaucoma Care
Procedures	CPT Code	Frequency	I&R
Anterior scanning laser	0187T	Annual (currently not covered)	Yes
Extended ophthalmoscopy	92225	At least annually (if no fundus photography)	Yes
Fundus photography	92250	At least annually	Yes
Gonioscopy	92020	At least annually	No
Pachymetry	76514	One time	No
Serial tonography	92100	Varies with severity and control	Yes
SGLT	92135	1 to 4 times per year (varies with severity)	Yes
Visual fields	92083	1 to 4 times per year (varies with severity)	Yes
Glaucoma screening	G0117	Annually if criteria met	N/A

Many Medicare carriers have developed guidelines that stipulate the number of supplemental tests that can be performed in a year. Be sure to follow the guidelines for your particular carrier for the frequency of these tests.

If a patient needs more frequent testing than is indicated by the Medicare carriers guidelines, be sure to have the patient sign the Advance Beneficiary Notice of Non-Coverage (ABN). File the test with a -GA modifier (denial expected but ABN on file). A new version of the ABN was released in April; its mandatory use will be required by September. Also, remember some of these codes require a separate I&R.

Of course, patients with glaucoma need periodic IOP and dilated fundus evaluations. These evaluations should occur at intervals appropriate for the severity of the glaucoma and are billed with the appropriate ophthalmic or E&M codes.

Medicare allows an annual glaucoma screening for all African American patients age 50 and over, Hispanic patients age 65 and over, patients with a family history of glaucoma, or patients with diabetes. This screening is filed using G0117 and the diagnosis of V80.1. Use this code if the patient does not have other ocular pathology.

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Clinical Coding Committee John Rumpakis, O.D., M.B.A., Clinical Coding Editor D.C. Dean, O.D. David Mills, O.D., M.B.A. Laurie Sorrenson, O.D. Rebecca Wartman, O.D.