Q: Among common eye diseases, where does glaucoma rank?
A: Based on incidence, age-related macular degeneration is the most common eye disease in the
As for glaucoma treatments, the Medicare database reveals some trends. Medicare utilization statistics for 2007, the most recent year of available data, show a 12-percent decrease in trabeculectomy claims (66170) and a 15-percent decrease in trabeculectomy with scarring (66172) from 2006 to 2007. The growth of laser trabeculoplasty (65855) from 2001 to 2005, due to selective laser trabeculoplasty, leveled off in 2006 and 2007. Implantation of aqueous shunt (66180) grew 18 percent and endoscopic cyclo-photocoagulation (66711) grew 27 percent.
A number of promising new procedures deserve attention including canaloplasty (0176T, 0177T) and new shunt procedures (0191T, 0192T), but no claim data is available yet.
Q: Do Medicare administrative contractors limit the number of glaucoma tests they cover?
A: Yes, but the policies vary; check your local MAC's website for specifics. Commonly, contractors limit pachymetry to once per lifetime for ocular hypertension and glaucoma.
Oftentimes, scanning computerized ophthalmic diagnostic imaging of the posterior segment (SCODI-P) is covered once or twice per year for moderate glaucoma and rarely for severe glaucoma. SCODI of the anterior segment (SCODI-A) is relatively new and coverage, where it exists, is indicated for narrow-angle glaucoma. Medical necessity for perimetry varies with the severity of the glaucoma. Typically, one field per year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and three times a year for unusual cases such as one-eyed patients. Of all tests, fundus photography of the optic disc is frequently described as the most valuable. Repeat photos are indicated when the eye exam reveals morphological changes in the optic nerve. In the same vein, repeat gonioscopy is indicated when the eye exam suggests angle changes. Other diagnostic tests for glaucoma such as ultrasonic biomicroscopy, serial tonometry, tonography, measurement of ocular blood flow and corneal hysteresis are rarely covered.
Some tests can be bundled when performed on the same day. The National Correct Coding Initiative designates fundus photography (92250) to be mutually exclusive with SCODI (92135). Visual fields (9208x) are mutually exclusive with each other; only the most extensive test should be billed. Gonioscopy (92020) is bundled with external photography (92285). A minimal eye exam (99211) is bundled with almost every ophthalmic diagnostic test; the technician's work is reimbursed within the technical component of the service.
Q: Are new glaucoma surgical procedures covered by Medicare and other third-party payers?
A: Sometimes. Payers look for high-quality, peer-reviewed scientific publications that demonstrate the clinical utility of a new procedure. Additionally, they are swayed by the opinions of experienced surgeons who provide personal testimonials regarding the value of new procedures compared with well-established surgical options. Finally, rapid adoption of a new procedure, as evidenced by popularity among surgeons, is a powerful indicator of merit. Initially, payers are generally skeptical of anything new but over time can be convinced to cover a new item or procedure that demonstrates better outcomes, greater safety or lower cost.
Because coverage policies early on are scant, obtain prior authorization from the payer on a case-by-case basis whenever possible. Before surgery, ask the patient to agree to be financially responsible if reimbursement is not forthcoming. Obtain a Medicare patient's signature on an Advance Beneficiary Notice of Noncoverage, or use another financial waiver form for other payers. The surgeon and the facility should each obtain the signed forms independently.
Q: How did the ambulatory surgery center payment system change the way glaucoma procedures are reimbursed?
A: Medicare's ASC payment system eliminated separate payment for aqueous shunts, scleral patch grafts and amniotic tissue. Instead, the facility fee includes these surgical supplies as incidental ingredients; balance billing beneficiaries for the cost of these items is prohibited. The four-year phase-in of the system gradually increases the facility fee for many procedures to compensate for this shift; however, ASCs find it economically challenging to provide services with high-cost bundled supplies.
The new system expanded the list of eligible procedures that can be performed in an ASC and reimbursed by Medicare. Most notably, glaucoma laser procedures be-came eligible for facility reimbursement on January 1, 2008. Reimbursement for surgeries formerly performed in-office is slightly lower when performed in the ASC.
Some postop procedures are also covered. Medicare's global surgery rules consider managing a postop complication in the office as part of the global surgery package and not separately reimbursed. Medically necessary return trips to the operating room (but not a minor procedure room), for any reason and without regard to fault, are separately reimbursed, but at a reduced rate with the use of modifier -78.
Ms. McCune and Mr. Corcoran are vice president and president of Corcoran Consulting Group, respec-tively. Ms. McCune can be contacted by email at
DMcCune@corcoranccg.com, and Mr. Corcoran can be reached at KCorcoran@corcoranccg.com.
