How to calculate the frequency of Glucoma screening for coverage

Calculating the Frequency
• 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 the count beginning with the month after the month in which the previous covered screening procedure was performed.

o Diagnosis Coding Requirements

• Providers bill glaucoma screening using screening (“V”) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma). Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.

o Payment Methodology

• Carriers
o Contractors 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 (refer to the Medicare Claims Processing Manual, Chapter 12, “Physician/Non-physician Practitioners,” for more information about the Medicare limiting charge).


o Payment is made for the facility expense as follows:
• Independent and provider-based RHC/free standing and provider-based FQHC - payment is made under the all inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;
• CAH - payment is made on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in the Medicare Claims Processing Manual
• CORF - payment is made under the Medicare physician fee schedule;
• Hospital outpatient department - payment is made under outpatient prospective payment system (OPPS);
• Hospital inpatient Part B - payment is made under OPPS;
• SNF outpatient - payment is made under the Medicare physician fee schedule (MPFS); and
• SNF inpatient Part B - payment is made under MPFS.
Deductible and coinsurance apply

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