Preventive Services

Preventive Services Guide


Glaucoma Screening

Glaucoma is a group of eye diseases in which damage to the optic nerve results in loss of eyesight. Medicare beneficiaries over the age of 60 have an increased risk of developing glaucoma. CMS has determined that the evidence is adequate to conclude that a screening for glaucoma is reasonable and necessary for the early detection or prevention of an illness or disability and is appropriate for certain Medicare eligible individuals.

Coverage Criteria and Frequency Limits

Covered once every 12 months (11 full months must pass before next screening) for beneficiary’s who fall into at least one of the following high risk categories:

  • Individuals with diabetes mellitus
  • Individuals with a family history of glaucoma
  • Black or African-Americans aged 50 and older
  • Hispanics or Latinos aged 65 and older

Risk Factors

  • Age
  • Race
  • Family history
  • Medical history

Screening Components Include:

  • Dilated eye examination with an intraocular pressure (IOP) measurement
  • Direct ophthalmoscopy examination or a slit-lamp bio microscopic examination 

HCPCS/CPT Coding

  • G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
  • G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

Diagnosis Coding

  • Z13.5: Encounter for screening for eye and ear disorders

Documentation

  • Beneficiary is one of the high-risk groups
  • Appropriate screening was performed
  • Legible signature of person performing service with credentials

Who Can Perform?

  • Must be furnished by or under direct supervision of optometrist or ophthalmologist

Cost Sharing

  • Copayment/coinsurance applies
  • Deductible applies

Reimbursement

Nonparticipating Providers:

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Common Claim Denial Reasons

  • Benefit maximum for this time period has been reached
  • Services not covered unless patient is classified as at high risk

Noncovered Routine Vision Services

  • Eyeglasses
  • Eye exams

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Reviewed 9/27/2024