In optometry school, we are taught how to identify and treat glaucoma, but not always how, specifically, to schedule these patients and what a glaucoma consultation and follow-up entail. This includes required diagnostic testing and procedure codes* and the decision-making involved with proper exam coding.

With that said, here I discuss these practice management items.

STAFF TRAINING

In my experience, this starts with cross-training on how to efficiently administer all glaucoma diagnostic testing, as well as assist providers with patient charting. In the practice at which I work, this training is done by a designated trainer, who creates the training curriculum and makes sure new hires hit pre-determined training checkpoints in a timely matter. This helps us limit the productivity loss that typically results from this position's high turnover rate. If it isn’t feasible for the O.D. to have a full-time tech-training position, it is still important to have a training checklist and specific staff (as-needed or part time) who are responsible for guiding new hires until they are efficient on their own.

SCHEDULING PATIENTS

Also important is a patient schedule that allows for flexibility, should doctors get behind. Our typical schedule is in an upside-down pyramid. (See "Patient Scheduling," p.31.) Some patients may need more time than expected, and with a full schedule, doctors tend to fall behind. If the O.D. front-loads the schedule, the decreasing frequency with which patients are scheduled balances this tendency and allows for a more even clinic flow.

GLAUCOMA CONSULTATION/FOLLOW-UP

Patient history, IOP and slit lamp exam, among other elements of a glaucoma exam, are not specifically billed as individual codes, so not listed. Where I practice, we use the following diagnostic tests:

• Goldmann applanation tonometry (GAT). (GAT) is maybe the most important diagnostic tool we have in glaucoma, and the GAT technique is still the gold standard. This technique is performed for all glaucoma patients at every encounter. Routine tonometry is bundled with the exam code and, therefore, not separately billed. Serial tonometry (92110) can be billed if the IOP is checked three or more times within the same session. Examples of serial tonometry are establishing a diurnal IOP curve and re-checking a patient's IOP after a high reading to ensure treatment is working. I consider establishing a diurnal IOP curve in cases in which a patient’s glaucoma is progressive, but the IOP is well controlled. Some providers may use continuous IOP monitoring technology and bill a 0329T for this service. This is emerging technology, and we do not currently offer it at our practice.
• VF. This testing, if possible, is completed the same day, for established patients. We bill a 92083 for all VF testing in our glaucoma practice, as 24-2 and 10-2 testing meets the threshold for extended perimetry.
• OCT. We use three main types of OCT testing. First is an anterior segment OCT (92132), called “HD-angle” to help us determine whether the angle is open enough for safe pupil dilation. The second and third types are optic nerve RNFL and GCC OCT testing, both coded as a 92133, as they are both paired with a glaucoma diagnosis. OCT testing is typically ordered for new patients and annually there-after, if frequent and fast progression is noted. (A Caveat: Coding requirements differ for different insurances, so O.D.s should look at their manual for rules on this approach.)
• Stereo disc photography. We acquire these photographs (92250) on all new glaucoma patients to capture pathology for treatment and monitoring purposes. Typically, we take these at the first follow-up exam, as fundus photography is bundled with OCT testing and, thus, cannot be separately billed on the same day at the initial visit. Additionally, I order these photographs when I suspect a change in optic disc appearance.
• Gonioscopy. We perform this essential diagnostic technique (92020) on all new patients requiring a glaucoma evaluation, and it can be billed for at any time. I repeat this technique more frequently on patients who have borderline narrow angles, are phakic or at high-risk, due to peripheral anterior synechiae.
• Pachymetry. Corneal thickness (76514) is typically a one-time measurement we acquire at the patient’s first visit, unless there is a change due to corneal pathology, surgery or clinical edema. This can be billed for at any time.
• Corneal hysteresis. Other practices may employ corneal hysteresis (92145) and electroretinography (92273, 92274, 0509T) to aid in the diagnosis and monitoring of glaucoma. For information on these tests, see “Snatch the Silent Thief,” p.20.)

CODING DECISION-MAKING

As is the case with other subspecialties of eye care, optometrists are able to utilize two types of codes when coding for glaucoma exams: Evaluation and management (E/M) codes (992XX) and Eye (visit) codes (920XX). Each type has different sets of rules and requirements for use, and many times insurance providers accept these codes differently. These rules, requirements and more are outlined at https://go.cms.gov/2PzvXA7 and https://bit.ly/38O7ZsN . As is the case with many O.D.s, I have found that billing and coding can become a challenge in a busy optometric practice. That said, I’ve found that five considerations have enabled me to select the proper exam codes:

1. Completeness of the exam. This is comprised of the chief complaint and the level of history taken. Typically, our dilated glaucoma patients meet the work-up requirements for a level 4 E/M code or a comprehensive (92004/92014) Eye code, and our undilated follow-up patients fall under a level 3 E/M or intermediate (92002/92012), as long as I perform an undilated evaluation/ophthalmoscopy of the optic disc.
2. Medical decision-making. This is the number of diagnoses, amount of testing with interpre­tation and the risk associated with the diagnosis/management options. The last is often the most important, as increased risk can elevate the exam code. In my exam chart plan, I make sure to record my interpretation of both external (outside clinic) and internal VF and OCT testing to make sure each element of decision-making is documented. I then consider whether the patient’s glaucoma is stable or to change the treatment plan. If I change treatment, I document the increased risk of progressive vision loss and increase a 99213 to a 92012/99214 or a 99214 to a 92014. Eye codes require a change in treatment plan to be used.
3. Reimbursement. A hierarchy of codes directly relates to the amount of work done by the provider and complexity of the decision-making. Despite small regional differences, the general ranking of reimbursement values per E/M and eye level codes remains the same. Lowest to highest level of reimbursement: New patients:* 99201<99202<92002*<99203<92004<99204<99205 Established patients: 99211<99212<99213<92012<99214<92014<99215 *Underlined denotes Eye code.
4. New or Established patient. For new patients (not seen within three years of the exam date) receiving a full dilated exam, I use E/M 99204, as it is a more appropriate code. If the patient is established, I look to the insurance provider to make a determination. Medicare allows Eye codes for medical eye exams, whereas many private insurances consider eye codes as “vision exams” only. To simplify my approach, I support codes for Medicare.

PUTTING IT TOGETHER

Here are some coding examples:

• Case 1: A new glaucoma patient referred to our clinic for evaluation. Full dilated exam is done with standard testing. The patient has well-controlled glaucoma.
  1. Exam code: E/M 99204. Note: poorly controlled glaucoma also with same code.
  2. Testing done: GAT, 24-2 VF, HD angle OCT, RNFL/GCC CT, macula OCT, gonioscopy, pachymetry.
  3. Testing billed: extended threshold perimetry (92083), RNFL OCT (92133), gonioscopy (92020), pachymetry (76514)
  The first follow-up timing depends on the glaucoma risk or severity. Typically, I have lower risk suspects and mild glaucoma patients return once or twice a year with annual OCT and VF testing. For higher risk and more advanced glaucoma, the frequency increases to at least quarterly visits with VF testing every six months and 10-2 testing, as indicated.
• Case 2: First follow-up visit three months after initial diagnosis. At this visit, an undilated IOP check is performed with 90-D optic disc evaluation. IOP is above target, and treatment is changed.
  1. Exam code: 99214 (high risk/decision-making)
  2. Testing done: 10-2 VF, stereo disc photos
  3. Testing billed: VF (92083) and fundus photography (92250)
• Case 3: Patient returns for dilated glaucoma evaluation: poorly controlled. Change in medication.
  1. Exam code: 99214 (private insurance), 92014 (Medicare)
  2. Testing done: 24-2 VF, RNFL/GCC OCT testing
• Testing billed: extended threshold perimetry (92083), RNFL OCT (92133)

FILLING IN THE BLANKS

Optometry school does not always ready us for practice management. I hope the information here will facilitate efficient glaucoma scheduling and coding/billing and inspire active diagnosis. OM

* The information provided in this article relates to general optometric practices. All testing, follow-up appointments and billing and coding should follow the guidelines of the patient’s insurance plan, when that is being utilized.

DR. CLERMONT practices at Northwest Eye Surgeons, where he provides postoperative and medical eye care at the practice's Seattle clinic. He received training at VA Puget Sound Health Care System – American Lake Division, Lakewood, Wash.; Optometric Residency. He has no disclosures.