Optometry ­Glaucoma Screenings

Have you implemented glaucoma screenings in your optometry practice? If not, then this article will hopefully give you some insights as to the benefits and approach of glaucoma management.

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. 

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. 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. In addition, offering glaucoma screenings allowed for increased reimbursement, since it is billed as a medical optometry service. Other benefits include the ability to catch high risk patients for referral, or to begin glaucoma management in your office.

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, age, family history of glaucoma, hypertension, steroid use, and eye injuries. African descent is a risk factor as glaucoma is 6 times more common in African Americans compared to Caucasians. Asian descent has increased incidents of angle closure glaucoma, and Japanese descent in particular has a higher percentage of normal tension glaucoma. Hispanic ethnic backgrounds are shown to be at higher risk for primary open angle glaucoma. In my patient base, I also look for clinical findings such as high myopia, thin central corneal thickness less than 500 microns, and asymmetric intraocular pressure greater than 2 mmHg.

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, and Ophthalmoscopy. Corneal Pachymetry and Gonioscopy are additional tests that we added to complete a thorough glaucoma screening. If you use electronic health records (EHR) in your practice, look out for how to properly document this data in the software. 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.

Ophthalmoscopy documentation in EyePegasus EHR:

Gonioscopy documentation in EyePegasus EHR:

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. 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. 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.

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. 

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. 

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. 

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.

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.