Effective October 1, 2011, there were new Medicare classifications for the diagnosis of glaucoma. Effective January 1, 2012, all insurers had to make this change. The reasoning behind the new staging codes was that patients present for treatment at different stages of the disease. It is important to identify the stages of glaucoma to monitor patient treatment and outcome. The new codes will not impact coverage, but in the future, allocations for allowable payments are anticipated to be paid on the severity of the disease. The new changes are as follows:
365.0 Borderline glaucoma (glaucoma suspect) is revised to:
365.00 – Preglaucoma, unspecified
365.01 – Open angle with borderline finding, low risk (1-2 risk factors)
365.02 – Anatomical narrow angle, now included added language “Primary angle closure suspect”
The new glaucoma suspect codes are:
365.05 – Open angle with borderline findings, high risk (3 or more risk factors)
365.06 – Primary angle closure without glaucoma damage (synechiae in angle or high IOP)
The new stage codes are:
365.70 – Glaucoma stage, unspecified
365.71 – Mild stage glaucoma
365.72 – Moderate stage glaucoma
365.73 – Severe stage glaucoma
365.74 – Indeterminate stage glaucoma
The stage codes are reported with these series of glaucoma diagnosis codes:
Open angle glaucoma 365.10-365.13
Angle closure glaucoma 365.20-364.23
Corticosteroid induced glaucoma 365.31
Glaucoma associated with disorders of the crystalline lens 365.52
Glaucoma associated with other ocular disorders 365.62-365.65
Make sure all procedures are linked to the actual glaucoma diagnosis, not the stage diagnosis. The glaucoma stage may not be assigned as a principal or first-listed diagnosis. The stage codes are not reported with glaucoma suspect codes 365.00-365.06
The stage coding is based on the eye care professional’s judgment. There are several different definitions of the stages, which will be summarized below.
Mild Damage — American Optometric Association Definition
- Optic Nerve – mild concentric narrowing or partial localized narrowing of the neuroretinal rim; disc hemorrhage; cup/disc asymmetry
- Nerve Fiber Layer – less bright reflex; fine striations to texture; large retinal blood vessels clear; medium retinal blood vessels less blurred; small retinal blood vessels blurred
- Visual Field – isolated paracentral scotomas; partial arcuate or nasal step; damage limited to one hemifield with fewer than 25% of points involved, mean deviation (MD) less than -6 dB
Mild Damage — American Academy of Ophthalmology Definition
- Optic nerve changes consistent with glaucoma but NO visual field abnormalities on any visual field test OR abnormalities present only on short-wave-length automated perimetry or frequency doubling perimetry
Mild Damage — CMS Definition
- One or more of the following in the worst eye
- Intraocular pressure >22mmHG
- Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ration > 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 — American Optometric Association Definition
- Optic Nerve – moderate concentric narrowing of the neuroretinal rim; increase in the area of central disc pallor; a complete localized notch or loss of the neuroretinal rim in one quadrant; undermining of vessels
- Nerve fiber layer – minimal brightness to reflex; no texture; large, medium, and small retinal blood vessels clear
- Visual field – partial or full arcuate scotoma in at least on hemifield; damage may involve both hemifields; fixation should not be involved; mean deviation between -6 dB and -12 dB
Moderate Damage — American Academy of Ophthalmology Definition
- Optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation.
Moderate Damage — CMS Definition
- One or more of the following in the worst eye
- Enlarged optic cup with neural rim remaining but sloped or pale, cup/disc ration >0.5 but <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
Severe Damage — American Optometric Association Definition
- Optic Nerve – complete absence of the neroretinal rim in at least three quadrants; bayoneting of vessels; markedly increased area of central disc pallor
- Nerve fiber layer – reflex dark; no texture; large, medium, and small retinal blood vessels clear
- Visual field – advanced loss in both hemifields; 5-10 degrees central island of vision; mean deviation worse than -12 dB
Severe Damage — American Academy of Ophthalmolgy Definition
- Optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least on hemifield.
Severe Damage — CMS Definition
- One of more of the following in the worst eye
- Severe generalized constriction of isopters
- Absolute visual defects within 10 degree 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 >0.8
- Wipeout of all or a portion of the neural retinal rim
If both of the patient’s eyes are glaucomatous, always report for the more severe stage of the two eyes. If the two eyes have different types of glaucoma, document each eye with its type and assign a stage code for each eye.
The indeterminate code would be used when you see a patient that you haven’t yet had time to do a visual field on, the patient just can’t perform a visual field test, or it’s so unreliable or uninterruptable that you really are unsure what level or state they are at.
According to WPS, OCT is considered reasonable and necessary when performed on an annual basis for patients with a diagnosis of glaucoma or glaucoma suspect, and on six month intervals for patients with low tension glaucoma. More frequent OCT may be approved when submitted with documentation describing the medical circumstance relating to the patient’s condition explaining the need for more frequent services or extra visits.
For visual fields, the frequency of visual fields is dictated by the stage of disease or degree of risk factors. Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary. Examinations found to have been performed at a frequency greater than is necessary for reasonable medical management of the patient’s condition are not covered. An advance Beneficiary Notice should be singed prior to the service if you feel Medicare will not pay due to frequency and you feel the test is necessary.
Other insurance carriers, allow 1 scanning laser per year for mild or suspect glaucoma, 2 per year for moderate glaucoma, and none for severe glaucoma. Most will allow up to four visual fields per year for severe glaucoma.
Another new code for glaucoma is in the V19 series, the Family History of Other Conditions. The new code is V19.11, used for a family history of glaucoma. This code is never used alone. The actual condition is listed first, such as glaucoma suspect.
These changes will help prepare doctors for the ICD-10 conversion in October 2013 and are similar in concept the recent PQRS initiatives of reporting “what you find.” For additional resources, refer to www.aoacodingtoday.com, www.aoa.reimbursementplus.com or send questions to AskTheCodingExperts@aoa.org
A Glaucoma staging codes teaching module can be found at SurveyMonkey.com.