(Medicare Claims Processing Manual)

The following HCPCS codes should be reported when billing for screening glaucoma services:   G0117 -  Glaucoma screening for high- risk patients furnished by an optometrist (physician for A/B MAC (B)) or ophthalmologist.   G0118 -  Glaucoma screening for high- risk patients furnished under the direct supervision of an optometrist (physician for A/B MAC (B) or ophthalmologist.   The A/B MAC (B) claims type of service for the above G codes is: TOS Q.   Glaucoma screening claims should be billed using screening (V) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma), or if ICD -10-CM is applicable, diagnosis code Z13.5 (encounter for screening for eye and ear disorders).  Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable (refer to chapter 1 of this manual for more information about incomplete or invalid claims).   70.1.1.1 - Additional Coding Applicable to Claims Submitted to A/B MACs (A)  (Rev. 371, Issued 11- 19-04, Effective: 04 -01-05, Implementation: 04- 04-05)  A. Type of Bill   The applicable A/B MAC (A) claim bill types for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X.  (See instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).)   B. Revenue Coding   The following revenue codes should be reported when billing for screening glaucoma services:  Comprehensive outpatient rehabilitation facilities (CORFs), critical access hospitals (CAHs), and skilled nursing facilities (SNFs) bill for this service under re venue code 0770.  CAHs electing the optional method of payment for outpatient services also report this service under revenue codes 096X, 097X, or 098X.  Hospital outpatient departments bill for this service under any valid/appropriate revenue code.  They are not required to report revenue code 0770.  (See instructions below for RHCs and FQHCs.)   70.1.1.2 - Special Billing Instructions for RHCs and FQHCs  (Rev. 371, Issued 11- 19-04, Effective: 04 -01-05, Implementation: 04- 04-05)  Screening glaucoma services are considered RHC/FQHC services.  For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC re venue code 0520 or 0521 to report the related visit.  Reporting of revenue code 0770 and HCPCS codes G0117 and G0118 in addition to revenue code 0520 or 0521 is required for this service in order for CWF to perform frequency editing.  Payment should not be  made for a screening glaucoma service unless the claim also contains a visit code for the service.  A/B MACs (A) must edit to assure payment is not made for revenue code 0770.  The claim must also contain a visit revenue code (0520 or 0521).  Payment is m ade for the screening glaucoma service under the all -inclusive rate for the line item reporting revenue code 0520 or 0521.  No payment is made on the line item reporting revenue code 0770.   Screening glaucoma services furnished within an RHC/FQHC by a physician or nonphysician are considered RHC/FQHC services.  For claims with dates of service on or after April 1, 2005, RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X for the se rvice.  Payment is made under the all -inclusive rate.  Additional revenue and HCPCS coding is no longer required for this service when RHCs/FQHCs are billing for the service.  Use revenue code 0520 or 0521, as appropriate.   70.1.2 - Edits  (Rev. 1, 10- 01-03)  B3-4184.4, A -01-132 (CR 1914), B3- 4184.5   A. Common Working File Edits   Effective January 1, 2002, CWF edits glaucoma screening claims for frequency and valid HCPCS codes for dates of service January 1, 2002, and later.   B. Claims Edits   Nationwide claims processing edits for pre or post payment review of claim(s) for glaucoma screening are not required at this time.  A/B MACs (A) and (B) monitor claims to assure that they are paid only for covered individuals and perform medical review as appropriate.  Local medical review policies and edits may be developed for such claims.   70.2 - Payment Methodology  (Rev. 1, 10- 01-03)  B3-4184.7, A -01-132 (CR 1914), A -01-105(CR 1783), B -01-46 (CR 1717)   A/B MACs (B) pay for glaucoma screening based on the Medicare Physician Fee Schedule.  Deductible and coinsurance apply.  Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, which means they  cannot charge the beneficiary more than 115 percent of the allowed amount.   A/B MAC (A) pay the facility expense as follows:    Independent and provider -based RHC/free standing and provider -based FQHC receive payment under the all -inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;   CAHs receive payment on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in Chapter 4 should be followed;    CORFs receive payment under the Medicare Physician Fee Schedule;    Hospital outpatient departments receive payment under the outpatient prospective payment system (OPPS);    Hospital inpatient Part B services are paid under OPPS;    SNF outpatient services are paid under the Medicare physician fee schedule (MPFS); and    SNF inpatient Part B services are paid under MPFS.   Deductible and coinsurance apply.   70.3 - Determining the 11 -Month Period  (Rev. 1, 10- 01-03)  A-01-132 (CR 1914), B3 -4184.3  Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed.  To determine the 11- month period, start counts beginning with the month after the month in which the pr evious covered screening procedure was performed.   70.4 - Remittance Advice Notices  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Appropriate remittance advice(s) must be used by A/B MACs (A) and (B) when denying payment for glaucoma screening.  The following messages are used where applicable:    If the services were furnished before January 1, 2002, use existing ASC X12 835 remittance advice claim adjustment reason code 26 Expenses incurred prior to coverage at the line level.    If the claim for glaucoma screening is being denied because the minimum time period has not elapsed since the performance of the same Medicare covered procedure, use existing ASC X12 835 claim adjustment reason code 119 Benefit maximum for this time perio d has been reached at the line level.    If the service is being denied because the individual is not an African -American age 50 or over, use existing remittance advice claim adjustment reason code 6, The procedure code is inconsistent with the patients age, and existing remark codes M83, Ser vice not covered unless the patient is classified as at high risk, and M82, Service not covered when patient is under age 50.  Report these codes at the line level.    If the service is being denied because the individual is not a Hispanic -American age 65 or over, use existing remittance advice claim adjustment reason code 96, Non -covered charge, and existing remark codes M83, Service 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."    If the service is being denied because the patient does not have diabetes mellitus, or there is no family history of glaucoma,  A/B MACs (B) use existing remittance advice claim adjustment reason code B5, Payment adjusted because coverage/program guidelin es were not met or were exceeded.  The zero payment for the service will indicate the denial.  In addition, report remark code M83, Service is not covered unless the patient is classified as at high risk at the line level.   70.5 - MSN Messages (Rev. 895, Issued:  03- 24-06; Effective:  01 -01-06; Implementation:  04 -03-06)  The following MSN messages where appropriate must be used.  If a claim for a screening for glaucoma is being denied because the service was performed prior to January 1, 2002, use the MSN message:   MSN Message 16.54:   This service is not covered prior to January 1, 2002.  The Spanish version of the MSN message should read:   Este servicio no est cubierto antes del 1 de enero de 2002.  If a claim for screening for glaucoma is being denied because the minimum time period has not elapsed since the performance of the same Medicare- covered procedure, use MSN message:   MSN Message 18.14:   Service is being denied because it has not been [12/24/48] months since your last [test/procedure] of this kind.   The Spanish version of this MSN message should read:   Este servicio est siendo denegado ya que no han transcurrido [12, 24, 48] meses desde el ltimo[examen/procedimiento] de esta clase.   If a claim for a screening for glaucoma is being denied because the age- related and/or ethnic -related coverage criteria are not met, use:   MSN Message 21.21:   This service was denied because Medicare only covers this service under certain circumstances.   The Spanish version of this MSN message should read:   Este servicio fue denegado porque Medicare solamente lo cubre bajo ciertas circunstancias.   80 - Initial Preventive Physical Examination (IPPE)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  (NOTE:  For billing and payment requirements for the Annual Wellness Visit, see chapter 18, section 140, of this chapter.)   Background :  Sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11)) authorize coverage under Part B for a one -time initial preventive physical examination (IPPE) for new Medicare b eneficiaries that meet certain eligibility requirements.   Coverage :  As described in implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11), the IPPE may be performed by a doctor of medicine or osteopathy as defined in section 1861 (r)(1) of the Social Security Act (the Act) or by a qualified nonphysicia n practitioner (NPP) (physician assistant, nurse practitioner, or clinical nurse specialist), not later than 12 months after the date the individuals first coverage begins under Medicare Part B. (See section 80.3 for a list of bill types of fac ilities that can bill A/B MACs for this service.)   The IPPE includes:   (1) review of the individuals medical and social history with attention to modifiable risk factors for disease detection,   (2) review of the individuals potential (risk factors) for depression or other mood disorders,   (3) review of the individuals functional ability and level of safety;   (4) an examination to include measurement of the individuals height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiarys medical and social history;   (5) end-of-life planning, upon agreement of the individual.  (6) education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and