Issue 2006-05, May 2006

Expansion of Glaucoma Screening Services

Provider Types Affected
Physicians and providers who submit claims to Medicare fiscal intermediaries (FIs) and carriers for glaucoma screening examinations

Important Points to Remember

• CR4365 provides notice that beginning January 1, 2006, the definition of an eligible beneficiary in a high-risk category is expanded to include Hispanic Americans age 65 and over.
• Because of this revised definition, Medicare will pay for glaucoma screening examinations for Hispanic Americans age 65 and older when they are furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist who is legally authorized to perform the services under state law.
• If service is denied because the individual does not meet the age-related and/or ethnic-related coverage criteria, Medicare contractors will return Medicare Summary Notice 21.21 (This service was denied because Medicare only covers this service under certain circumstances).
• If service is denied because the individual is not a Hispanic American age 65 or over, the remittance advice claim will show reason adjustment code 96 (Noncovered charge), and existing remark codes M83 (Services not covered unless the patient is classified as at high risk), and N129 (This amount represents the dollar amount not eligible due to patient’s age.).
• Your Medicare FI or carrier will not search for or adjust claims with dates of service January 1, 2006, that were processed before the April 3, 2006, implementation date of CR4365. They will adjust any such claims that you bring to their attention.
• The following HCPCS codes apply for glaucoma screening:

G0117 Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; and

G0118 Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist or ophthalmologist.

Background
On January 1, 2002, CMS implemented regulations at 42 CFR, Section 410.23(a)(2). The regulations set conditions for and limitations on coverage of screening for glaucoma, requiring that the term “eligible beneficiary” be defined to include individuals in the following high-risk categories:

• Individuals with diabetes mellitus;
• Individuals with a family history of glaucoma; or
• African Americans age 50 and over.

The Physician Fee Schedule for Calendar Year 2006 Final Rule, 70 FR 70270, dated November 21, 2005, expands Medicare coverage of high-risk individuals eligible to receive glaucoma screening services to include Hispanic Americans age 65 and over.

This expansion of coverage is effective for services performed on or after January 1, 2006, and revises 42 CFR, section 410.23(a)(2) accordingly.

Implementation
The implementation date for this instruction is April 3, 2006.

Additional Information
The official instructions (CR4365) issued to your FI or carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R48BP.pdf    and http://www.cms.hhs.gov/Transmittals/downloads/R895CP.pdf    on the CMS Web site.

If you have questions, please contact your Medicare FI or carrier at their toll-free number which may be found at http://www.cms.hhs.gov/apps/contacts/   on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Medlearn Matters Number: MM4365
Pub. 100-4, Transmittal# R895CP, CR# 4365
Pub. 100-3, Transmittal# R48BP, CR# 4365
Related CR Release Date: March 24, 2006
Effective Date: January 1, 2006
Implementation Date: April 3, 2006