Medical Optometry Glaucoma Screenings

Introduction

Currently all states allow optometrists to manage glaucoma. For example, in California, the California Access to Vision Bill (Senate Bill 1406) was passed in 2008, which automatically granted newly licensed optometrists glaucoma management certification. Optometrists who obtained their license prior to 2008 have the ability to earn their certification through additional CEs.

Benefits for Your Practice

My name is Dr. Mai Dinh and I'm a licensed optometrist in California. When I implemented glaucoma screenings to the offices I practice in, we right away realized significant benefits for our patients and the office.

• Save patients time by not having to go to another provider for baseline screening
• Increased reimbursement through medical optometry billing
• Ability to catch high-risk patients for referral
• Begin glaucoma management directly in your office

Introducing glaucoma screenings was an easy, simple process that helped save our patients time by not having to go to another provider for the same baseline screening.

Identifying High-Risk Patients

But how should an office go about implementing glaucoma screenings? Let's talk about which kinds of patients to look out for. Risk factors that help me flag patients for glaucoma screenings include:

• Race (African descent - 8 times more common in African Americans compared to Caucasians)
• Age
• Family history of glaucoma
• Hypertension
• Steroid use
• Eye injuries
• High myopia
• Thin central corneal thickness less than 500 microns
• Asymmetric intraocular pressure greater than 2 mmHg

Ethnic Risk Factors

Understanding ethnic risk factors is crucial for comprehensive glaucoma screening:

• Asian descent: Increased incidents of angle closure glaucoma
• Japanese descent: Higher percentage of normal tension glaucoma
• Hispanic ethnic backgrounds: Higher risk for primary open angle glaucoma

Required Screening Tests

Likely most offices are already doing most of the work needed to screen for glaucoma. During the comprehensive eye exam, you will find that three of five glaucoma screening tests are already performed:

• Tonometry
• Visual field testing
• Ophthalmoscopy
• Corneal Pachymetry (additional test)
• Gonioscopy (additional test)

If you use electronic health records (EHR) in your practice, look out for how to properly document this data in the software.

EHR Documentation with EyePegasus

We use EyePegasus iPad EHR in our office, which makes it extremely easy to capture glaucoma screenings and any required follow-up. For example, I document my Ophthalmoscopy findings with the EyePegasus drawing module that automatically auto-codes ICD-10 diagnosis codes, as well as the billable service code. With the easy-to-use touch interface, Gonioscopy findings are also easily captured and conveniently auto-coded in EyePegasus EHR.

• Document Ophthalmoscopy findings with the EyePegasus drawing module
• Automatic auto-coding of ICD-10 diagnosis codes
• Automatic billing service code generation
• Easy-to-use touch interface for Gonioscopy findings
• Convenient auto-coding in EyePegasus EHR

Ophthalmoscopy Documentation in EyePegasus EHR

The EyePegasus EHR provides a comprehensive fundus drawing tool for documenting ophthalmoscopy findings. The system includes:

• Clock-hour markings (I to XII) around the periphery
• Labeled anatomical structures: Optic Disc, Macula, Fovea, Blood Vessels
• Interactive drawing panel with various ocular findings icons
• Selection tools for hemorrhages, drusen, exudates, retinal tears, and more
• Ability to highlight specific areas of concern with colored markers

The drawing module makes it extremely easy to capture detailed ophthalmoscopy findings and automatically codes them for billing.

Gonioscopy Documentation in EyePegasus EHR

EyePegasus EHR includes a comprehensive gonioscopy documentation table for both eyes (OD and OS) with the following fields:

• Lens Type selection
• Pigment grading (0, 1+, 2+, 3+, 4+)
• Angle measurement in degrees (10°, 20°, 30°, etc.)
• Visible Structures: CB (Ciliary Body), SL (Schwalbe's Line), TM (Trabecular Meshwork)
• Iris Contour: Concave, Convex, or Flat
• PAS (Peripheral Anterior Synechiae): YES/NO
• NV (Neovascularization): YES/NO
• Indications: Glaucoma NOS, Narrow Angles, and other conditions

The structured documentation format ensures consistent and complete gonioscopy findings are captured for every patient.

Advanced Testing Options

For visual field testing, the standard is a Humphrey 24-2. I perform ophthalmoscopy on dilated pupils to better view the optic nerve, looking for retinal nerve fiber defects, large cup to disc ratios, or optic nerve asymmetry. Retinal photos or Optomap imaging would be a nice addition to track progressive changes in the optic nerve. Our patients seem to enjoy the review, as a picture is worth a thousand words.

• Humphrey 24-2 for standard visual field testing
• Ophthalmoscopy on dilated pupils for better optic nerve visualization
• Retinal photos or Optomap imaging for tracking progressive changes
• Ocular Coherence Tomographer for retinal nerve fiber level analysis
• OCT can observe the angle (similar to gonioscopy)
• Measure pachymetry accurately without physically touching the patient's eye

Additionally, Glaucoma management would definitely be made easier with an Ocular Coherence Tomographer as you can run retinal nerve fiber level analysis, observe the angle (similar to gonioscopy), and measure pachymetry quite accurately without physically touching the patient's eye. This isn't required but my patients love the efficiency and great imaging technology that OCT's and Optos can provide.

Imaging Integration with EyePegasus EHR

With EyePegasus EHR, which runs on the iPad, I have the ability to take high-resolution pictures of the imaging results and upload them directly to the patient's chart. That way, I can document my imaging findings and interpretations electronically and have all glaucoma screenings data in one convenient place.

Having all glaucoma screening data in one convenient place makes follow-up care and patient management much more efficient.

Billing for Screenings

In terms of billing, be sure to submit CPT code G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist) if the diagnostic testing such as an OCT scan or perimetry is ran by staff. If run by the optometrist, CPT code G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) needs to be billed. In EyePegasus EHR, these billing codes can be easily added and managed.

• CPT code G0118: When diagnostic testing (OCT scan or perimetry) is run by staff under supervision
• CPT code G0117: When testing is run directly by the optometrist or ophthalmologist
• EyePegasus EHR can easily add and manage these billing codes

Coverage

In terms of coverage, note that under medicare, annual glaucoma screenings are covered for beneficiaries who have diabetes mellitus, are african-american age 50 or older, are hispanic-american age 65 or older, or anyone with a family history of glaucoma.

• Diabetes mellitus
• African-American age 50 or older
• Hispanic-American age 65 or older
• Anyone with a family history of glaucoma

ICD-10 Codes

The appropriate ICD-10 code to bill for glaucoma screenings is Z13.5 (Encounter for screening for eye and ear disorders), along with any other diagnostic codes that you find during your screening. As mentioned previously, EyePegasus EHR auto-codes ICD-10 codes from the doctor's findings, which gives me a great shortcut in my overall exam documentation.

EyePegasus EHR auto-codes ICD-10 codes from the doctor's findings, which gives me a great shortcut in my overall exam documentation.

Referral Management

If, based on my findings, I need to refer the patient out to a Glaucoma specialist, I use EyePegasus EHR to generate a referral letter that my staff can easily customize, if needed.

Generally our customization needs are small since EyePegasus provides complete referral templates for specific use-cases.

Summary & Recommendation

In summary, glaucoma screenings are an easy way to expand a practice. By practicing medical optometry, I have seen that it allows my patients greater access to healthcare in a primary care setting, as well as benefits our office in billing medical visits.

If you have not already done so, I highly recommend implementing glaucoma screenings in your office and leverage an efficient EHR system for proper documentation and follow-up.