Robert E Rebello
As of Oct 1, 2011 new Glaucoma codes went into effect. The majority of Optometrists and Ophthalmologists are unaware or do not have a complete understanding of these new codes. At three Optometry meetings in October, most doctors and their staffs had not heard about these new codes.
We at EyeCOR have put together this article explaining the new codes and their proper usage.
The new Glaucoma codes are “Stage” codes which specify the level or Stage of Glaucoma severity.
The new Stage codes are:
- 365.70 – Unspecified Stage Glaucoma
- 365.71 – Mild or Early Stage Glaucoma
- 365.72 – Moderate Stage Glaucoma
- 365.73 – Severe Stage Glaucoma
- 365.74 – Indeterminate Stage Glaucoma
Use the appropriate Stage code for the patient’s worst eye.
These Stage codes are secondary and coded immediately after the actual Glaucoma Diagnosis code. Stage codes cannot be used without the primary Glaucoma Diagnosis.
Note: These new codes are in effect for Medicare. Other payers are required to use the new codes beginning January 1, 2012. At this time other payers may not recognize them.
The following Glaucoma codes require one of the Stage codes:
365.10, 365.11 365.12 365.13, 365.20, 365.23, 365.31, 365.52, 365.62, 365.63 and 365.65
Do not use the Stage codes for Glaucoma Suspect or other glaucoma diagnoses not included above.
Coding Tip: We recommend not using either 365.70 or 365.74 as they are “Unspecified” or “Indeterminate.” Frequently payers deny reimbursement for Unspecified diagnoses. Instead code the specific Stage of Glaucoma.
Coding Tip: Make sure all procedures that point to the Glaucoma diagnosis using the Diagnosis Pointer (Form Locator: 24 E) point to the actual Glaucoma diagnosis not the Stage diagnosis (See Coding Example 1).
Coding Example 1 - Mild - Primary Open Angle Glaucoma:
Coding Example 2 - Glaucoma Suspect (No Stage code):
Other Ramifications when using the New Stage Codes
Most regions restrict certain procedures based on Severity levels. One example is the frequency limitations for Scanning Laser (OCT, GDx and HRT). Previously, for Advanced Glaucoma damage, you could perform up to 4 Scanning Laser procedures per year. Most regions currently do not allow any Scanning Laser for Advanced or Severe Glaucoma damage. Instead payers may allow up to 4 Visual Fields per year in order to track damage.
Therefore, when you code 365.73 – Severe Stage Glaucoma you will likely be denied reimbursement for Scanning laser. In addition, if you now code “Severe” Glaucoma and previously performed Scanning Laser on this patient, the payer may look back at previous claims and demand you return reimbursement for those procedures.
The current frequency limitations for Scanning Laser for most regions are:
|Glaucoma Severity Level||Scanning Laser Frequency|
|Mild or Suspect Glaucoma||1 Time per year|
|Moderate Glaucoma||2 Times per year|
|Advanced or Severe Glaucoma||NO Scanning laser. Up to 4 Visual Fields|
Avoid the temptation to stay away from the “Severe” glaucoma code. If you are audited and found to be using incorrect Stage codes, you could be in for more trouble.
Glaucoma Suspect Code Changes
In addition to the new Stage codes for Glaucoma, CMS has also changed the descriptions for two Glaucoma Suspect codes (365.01-.02) and adding two new codes (365.05 -.06). The new descriptions and codes are:
- 365.01 – Open Angle Glaucoma with Borderline Findings – Low Risk
- 365.02 – Anatomical Narrow Angle – Primary Angle Closure Suspect
- 365.05 – Open Angle Glaucoma with Borderline Findings – High Risk
- 365.06 – Primary Angle Closure Without Glaucoma Damage
The differentiation is Low and High Risk and Closure without Glaucoma Damage.
Make sure when coding Glaucoma Suspect, you use the codes with the description matching the patient’s diagnosis.
Glaucoma Severity Definitions
CMS defines Glaucoma severity as follows. Make sure you use the correct Severity Level based on the worst eye:
|Glaucoma Suspect or Mild Damage (one or more of the following)|
|- Intraocular pressure >22 mmHg as measured by applanation. |
|- Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio Greater than 0.4. |
|- Focal optic disc notch. |
|- Optic disc hemorrhage or history of optic disc hemorrhage.|
|- Nasal step or small paracentral or arcuate scotoma. |
|- Mild constriction of visual field isopters.|
|Moderate Damage (one or more of the following)|
|- Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio Greater than 0.5 & Less than 0.9|
|- Definite focal notch with thinning of the neural rim.|
|- Definite glaucoma visual field defect (arcuate/paracentral scotoma, nasal step, pencil wedge, constriction of isopters|
|Advanced or Severe Damage (one or more of the following)|
|- Severe generalized constriction of isopters (i.e., Goldmann I4e <10 degrees of fixation).|
|- Absolute visual field defects within 10 degrees of fixation.|
|- Severe generalized reduction of retinal sensitivity|
|- Loss of central visual acuity, with temporal island remaining|
|- Diffuse enlargement of optic nerve cup, with cup to disc ratio Greater than 0.8|
|- Wipeout of all or a portion of the neural retinal rim.|
With the addition of the new Glaucoma Stage codes and new Glaucoma Suspect codes, proper coding can be complex. You need to ensure your practice is coding Glaucoma correctly. Otherwise, you could find your practice receiving unnecessary denials resulting in lost reimbursement.
For additional information contact EyeCOR:
Toll Free: 888-866-5367
Email: info@EyeCOR.com Copyright 2011 - Nteon Software LLC
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