Georgia Medicare Glaucoma Screening Guide (2026)

For every Georgia Medicare beneficiary at high risk for glaucoma asking whether their annual eye examination is Medicare-covered, every African American age 50 and older wondering whether routine eye health screening is reimbursed, every diabetic beneficiary navigating diabetic eye care and glaucoma screening coordination, every optometrist and ophthalmologist in Atlanta, Augusta, Savannah, Columbus, Macon, Albany, and rural Georgia communities performing screenings, and every Georgia caregiver supporting a family member through eye health care, the Medicare glaucoma screening benefit under Section 1861(uu) of the Social Security Act is a focused preventive coverage pathway. The Section 1861(uu) glaucoma screening benefit was established by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA, Public Law 106-554) and has been continuously available since the early 2000s.

By Brevy Care Team · Last verified May 21, 2026

Section 1861(uu) Glaucoma Screening: Statutory Framework

Section 1861(uu) of the Social Security Act

Section 1861(uu) of the Social Security Act (codified at 42 U.S.C. 1395x(uu)) defines the glaucoma screening service covered by Medicare. The statute:

• Defines "glaucoma screening" as a dilated eye examination with an intraocular pressure measurement and direct ophthalmoscopy or slit-lamp biomicroscopic examination
• Requires the screening to be performed or supervised by an optometrist or ophthalmologist authorized to provide such services under state law
• Limits coverage to high-risk individuals as defined by CMS

Section 1861(uu) was added to the Social Security Act by Section 102 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554) was a wide-ranging Medicare reform statute that expanded Medicare preventive coverage and made numerous payment and program improvements. BIPA Section 102 established Medicare coverage of glaucoma screening by:

• Adding Section 1861(uu) to the Social Security Act
• Authorizing CMS to specify high-risk categories
• Establishing an annual frequency
• Coordinating with the broader Medicare preventive services framework

Coverage took effect for screenings furnished beginning in the early 2000s under CMS implementing rulemaking. Beneficiaries and providers should consult current Medicare guidance for active effective dates and policy updates.

42 CFR 410.23 Implementing Regulations

Implementing regulations at 42 CFR 410.23 address glaucoma screening including:

• Definition of the glaucoma screening examination
• High-risk individual definition (the four eligibility categories CMS has specified)
• Annual frequency limitation
• Provider requirements (optometrist or ophthalmologist)
• Direct supervision requirements when supporting personnel perform components
• Conditions for coverage

Refer to the current regulation text on eCFR for the active enumeration of high-risk categories and supervisory standards.

Why No ACA Section 4104 Cost-Sharing Waiver

Section 4104 of the Patient Protection and Affordable Care Act eliminated Medicare cost-sharing for preventive services that meet either of two criteria:

• Recommended by the U.S. Preventive Services Task Force as Grade A or B, OR
• Specifically defined by Medicare as an enumerated preventive service eligible for the waiver

The USPSTF has not adopted a Grade A or B recommendation for routine glaucoma screening in asymptomatic adults; the current USPSTF assessment grades the evidence as insufficient (consult the USPSTF site for the most recent review). Glaucoma screening also was not specifically enumerated by Medicare for the cost-sharing waiver. Therefore, standard Part B cost-sharing (deductible plus coinsurance) applies to Medicare glaucoma screening.

This cost-sharing structure differs from many other Medicare preventive services (mammography, cardiovascular disease screening, diabetes screening, IPPE, AWV, etc.) that are covered at zero cost-sharing.

Section 1861(uu) Glaucoma Screening: High-Risk Eligibility Categories

Category 1: Diabetes Mellitus

Beneficiaries with diabetes mellitus are eligible for annual glaucoma screening regardless of age or other risk factors. Diabetes affects the eye in multiple ways:

• Increased risk of primary open-angle glaucoma
• Diabetic retinopathy (separately addressed under diabetic eye care)
• Increased risk of cataracts
• Other diabetes-related eye complications

The diabetes eligibility applies to all diabetes types including type 1, type 2, gestational diabetes history, and other specified diabetes types. The qualifying diabetes diagnosis must be documented in the medical record.

Category 2: Family History of Glaucoma

Beneficiaries with a family history of glaucoma are eligible for annual glaucoma screening regardless of age or other risk factors. Family history is generally defined as glaucoma in a parent, sibling, or child. The family history evidences genetic predisposition that elevates individual glaucoma risk.

Beneficiaries with paternal or maternal grandparent glaucoma history may also qualify in some clinical contexts. The documentation of family history relies on patient self-report and clinical judgment.

Category 3: African American Age 50 and Older

African American beneficiaries age 50 and older are eligible for annual glaucoma screening regardless of other risk factors. This category recognizes substantially elevated glaucoma prevalence and severity in the African American population, including:

• A meaningfully higher prevalence of primary open-angle glaucoma
• Earlier age of glaucoma onset
• More severe glaucoma progression
• Higher rates of glaucoma-related blindness

The age 50 threshold (rather than 65) reflects the earlier glaucoma onset documented in this population. The category is one of the most operationally important eligibility pathways given Georgia's substantial African American Medicare population.

Category 4: Hispanic American Age 65 and Older

Hispanic American beneficiaries age 65 and older are eligible for annual glaucoma screening regardless of other risk factors. This category recognizes elevated glaucoma risk in the Hispanic American population. The age 65 threshold aligns with the standard Medicare-eligibility age.

Overlapping Eligibility

Many beneficiaries qualify under multiple categories. For example, an African American age 60 with diabetes and a family history of glaucoma qualifies under three categories. The annual screening eligibility applies once per year regardless of how many qualifying categories apply.

Documentation of Eligibility

The ordering or screening provider documents the qualifying category in the medical record. Common documentation patterns:

• "Diabetes mellitus, eligible for annual glaucoma screening"
• "African American age 58, eligible for annual glaucoma screening"
• "Family history of glaucoma (mother), eligible for annual glaucoma screening"

Annual Screening Frequency

Once Per Year

Medicare covers glaucoma screening once per year (annually) for eligible high-risk beneficiaries. The annual frequency:

• Allows ongoing monitoring of intraocular pressure and optic nerve status
• Supports early detection of glaucoma progression
• Aligns with American Academy of Ophthalmology and American Optometric Association screening recommendations

A beneficiary screened on January 15 would generally be eligible for the next covered screening on or after the following January 15. The clock counts from the date of the prior covered screening.

What Counts as a Year

The annual frequency under 42 CFR 410.23 is generally interpreted as one screening per calendar year, or one screening with the required interval since the prior covered screening, depending on Medicare contractor interpretation. Most providers schedule screenings approximately 12 months apart to ensure clear eligibility.

Why Not More Frequent

Glaucoma is generally a slowly progressive condition. Annual screening provides adequate cadence for detection in stable high-risk populations. Beneficiaries with an established glaucoma diagnosis enter ongoing diagnostic and management eye care rather than continuing under the screening benefit.

Section 1861(uu) Glaucoma Screening: Examination Requirements

Dilated Eye Examination

The Medicare glaucoma screening requires a dilated eye examination. Dilation is achieved through topical mydriatic eye drops (typically tropicamide, phenylephrine, or a combination) administered before examination. Dilation allows the examining provider to:

• Visualize the optic nerve head clearly
• Assess optic disc cupping
• Evaluate optic nerve color and architecture
• Examine the retina for related pathology

Dilation typically lasts several hours. Beneficiaries should arrange for a driver or be prepared for blurred near vision and light sensitivity after the examination.

Intraocular Pressure (IOP) Measurement

IOP measurement (tonometry) is a required component of the glaucoma screening. Methods include:

Goldmann Applanation Tonometry

• Long considered a clinical reference standard for IOP measurement
• Uses topical anesthetic and fluorescein dye
• Performed at the slit-lamp biomicroscope
• Highly accurate

Non-Contact (Air-Puff) Tonometry

• Commonly used for screening
• No direct contact with the eye
• No anesthetic required
• Adequate accuracy for screening

iCare Tonometry

• Handheld rebound tonometry
• No anesthetic required
• Adequate for screening
• Useful in non-cooperative patients

IOP results are interpreted against current clinical reference ranges; consult current American Academy of Ophthalmology guidance for the IOP bands considered normal versus elevated. Elevated IOP is one of the most important glaucoma risk factors, although glaucoma can occur with normal-range IOP (normal-tension glaucoma) and elevated IOP can occur without glaucoma (ocular hypertension).

Direct Ophthalmoscopy or Slit-Lamp Biomicroscopic Examination

The screening requires direct ophthalmoscopy OR slit-lamp biomicroscopic examination of the optic nerve. The provider must assess:

• Optic disc cupping (cup-to-disc ratio)
• Disc rim integrity
• Neuroretinal rim thickness
• Disc hemorrhages (Drance hemorrhages)
• Peripapillary atrophy
• Nerve fiber layer thinning

Slit-lamp biomicroscopic examination with a high-magnification lens (e.g., Volk SuperField, 78D, 90D) provides higher-resolution optic nerve evaluation than direct ophthalmoscopy and is commonly used in current practice.

Additional Common Tests

While not strictly required by 42 CFR 410.23, providers often perform additional tests during glaucoma screening when clinically indicated:

• Visual acuity testing
• Visual field screening (perimetry)
• Pachymetry (corneal thickness measurement)
• Gonioscopy (anterior chamber angle assessment)
• Optical coherence tomography (OCT) of the optic nerve

These additional tests may be billed separately if performed for diagnostic reasons. For pure screening, the dilated exam with IOP and ophthalmoscopy or slit-lamp examination is the core requirement.

Provider Requirements

Optometrist or Ophthalmologist

The glaucoma screening must be performed or supervised by an optometrist or ophthalmologist authorized to provide such services under state law. Both provider types qualify under Medicare:

Ophthalmologists (MDs/DOs)

• Medical doctors specializing in eye care
• Complete medical school plus ophthalmology residency
• Can perform surgical procedures
• Often manage complex glaucoma cases

Optometrists (ODs)

• Doctors of Optometry
• Complete a 4-year optometry program after college
• State-licensed to perform comprehensive eye examinations
• Can prescribe medications for glaucoma in Georgia (under the Georgia Board of Optometry scope of practice)

Georgia State Licensure

Georgia licenses both optometrists (through the Georgia Board of Optometry) and ophthalmologists (through the Georgia Composite Medical Board). Most Georgia eye care providers carry Medicare provider numbers and accept Medicare assignment.

Direct Supervision

HCPCS G0118 represents glaucoma screening performed by supporting personnel under direct supervision of an optometrist or ophthalmologist. Direct supervision generally means the supervising provider is present and immediately available in the office suite, ready to provide assistance if needed.

Service Codes

G0117 Glaucoma Screening by Provider

HCPCS G0117 represents the glaucoma screening service for high-risk patients when the optometrist or ophthalmologist personally performs the examination. G0117 is the most commonly used code for glaucoma screening; refer to the current CMS HCPCS code descriptor for the active long-form definition.

G0118 Glaucoma Screening Under Direct Supervision

HCPCS G0118 represents the screening service when supporting personnel (e.g., trained technicians) perform components under the optometrist's or ophthalmologist's direct supervision. G0118 is less commonly used than G0117 because most glaucoma screening examinations require provider-level skill for optic nerve assessment.

Documentation Requirements

Documentation for G0117 and G0118 should include:

• Qualifying high-risk category
• Date of last screening (if applicable for frequency check)
• IOP measurement (right and left eye)
• Optic disc assessment findings
• Any abnormal findings or recommendations
• Provider signature

Cost-Sharing Structure

Standard Part B Cost-Sharing

Glaucoma screening is subject to standard Part B cost-sharing:

• Part B deductible: applies if not already met for the calendar year
• Coinsurance: after deductible, the beneficiary pays the standard Part B coinsurance percentage of the Medicare-approved amount
• Medicare pays: the remaining percentage of the approved amount

Refer to the current CMS Part B premium and deductible memo for active dollar amounts.

Medigap Supplement Coverage

Most Medicare Supplement (Medigap) plans cover the Part B coinsurance for glaucoma screening. Beneficiaries with Medigap plans typically have no additional out-of-pocket cost beyond their Medigap premium.

Medicare Advantage Coverage

Medicare Advantage plans must cover the same Medicare-defined preventive services as Original Medicare. Cost-sharing under Medicare Advantage depends on the plan's structure. Some plans waive cost-sharing for preventive services, others charge a small copay, and others maintain coinsurance similar to Original Medicare.

Why Cost-Sharing Differs From Other Preventive Services

Many Medicare preventive services (cardiovascular screening, diabetes screening, mammography, etc.) are covered at zero cost-sharing under ACA Section 4104. Glaucoma screening was not included in that cost-sharing waiver because:

• USPSTF has not provided a Grade A or B recommendation
• The benefit was established under a different statutory pathway (BIPA 2000)
• The current USPSTF assessment grades the evidence as insufficient

Beneficiaries and providers should understand this cost-sharing distinction.

Coordination With Diabetic Retinopathy Screening

Diabetic Eye Examinations

Beneficiaries with diabetes require comprehensive eye examinations to assess for diabetic retinopathy. Diabetic eye exams typically include:

• Visual acuity assessment
• IOP measurement
• Dilated fundus examination
• Optic nerve assessment
• Retinal photography (fundus photos)
• Optical coherence tomography (OCT)

Diabetic eye examinations are covered under standard Part B rules (not the glaucoma screening benefit) and use comprehensive ophthalmologic exam codes (e.g., 92002, 92004, 92012, 92014) plus diagnostic procedure codes for any additional tests.

Combined Encounters

In practice, diabetic Medicare beneficiaries often have a single comprehensive eye examination that:

• Fulfills the annual glaucoma screening requirement (G0117 reportable)
• Includes diabetic retinopathy assessment (separate exam codes for comprehensive exam)
• Captures both glaucoma and diabetic retinopathy evaluation

Providers can bill both the glaucoma screening (G0117) and the comprehensive ophthalmologic examination (e.g., 92014) when both services are clinically warranted and documented, although CMS coding rules may limit same-day billing in some scenarios. Practice patterns vary.

Diabetes-Specific Screening Recommendations

The American Diabetes Association and American Academy of Ophthalmology recommend annual dilated eye examinations for diabetic adults to assess for diabetic retinopathy. The Medicare glaucoma screening benefit complements this recommendation for diabetic beneficiaries who additionally have glaucoma risk factors.

Coordination With Annual Wellness Visit

AWV Eye Health Discussion

The Annual Wellness Visit under Section 1861(hhh) personalized prevention plan typically addresses eye health for at-risk beneficiaries:

• Identification of glaucoma risk factors (diabetes, family history, race/ethnicity)
• Recommendation for glaucoma screening when high-risk
• Referral to optometrist or ophthalmologist
• Coordination with broader preventive care

The primary care provider's AWV-driven referral often initiates the beneficiary's eye care relationship.

Why Primary Care Coordination Matters

Many Medicare beneficiaries do not routinely see eye care providers. Primary care AWV-driven referrals can significantly increase glaucoma screening utilization in high-risk populations. The AWV thus serves as an important entry point even though the AWV itself does not include the eye examination.

Glaucoma Disease Burden

Open-Angle Glaucoma vs Angle-Closure Glaucoma

Glaucoma encompasses several disease subtypes:

Primary Open-Angle Glaucoma (POAG)

• The most common form of glaucoma
• Slowly progressive
• Largely asymptomatic until advanced
• Elevated IOP is common but not universal
• Optic nerve cupping and visual field loss

Primary Angle-Closure Glaucoma

• Less common but more acutely symptomatic
• Sudden elevated IOP can cause eye pain, blurred vision, and halos
• Risk factors include hyperopia, shallow anterior chamber, age, and ethnicity
• May require laser iridotomy treatment

Secondary Glaucomas

• Result from other eye conditions or systemic factors
• Examples include pigment dispersion, exfoliation syndrome, neovascular glaucoma, and uveitic glaucoma

Why Asymptomatic Nature Matters

Primary open-angle glaucoma is largely asymptomatic until advanced stages. By the time beneficiaries notice visual field deficits or other symptoms, significant irreversible optic nerve damage may have occurred. The asymptomatic nature makes screening particularly valuable:

• Early detection allows treatment to slow progression
• Treatment cannot reverse existing damage
• Annual screening enables timely intervention

Treatment Pathway

If screening identifies elevated IOP, optic disc abnormalities, or other concerning findings, the beneficiary is referred for comprehensive diagnostic evaluation including:

• Visual field testing (Humphrey perimetry)
• Optical coherence tomography (OCT) of the optic nerve and retinal nerve fiber layer
• Gonioscopy
• Repeat IOP measurements
• Pachymetry

Treatment for diagnosed glaucoma includes:

• Topical IOP-lowering eye drops (prostaglandin analogs, beta blockers, alpha agonists, carbonic anhydrase inhibitors)
• Laser trabeculoplasty (SLT, ALT)
• Glaucoma surgical procedures (trabeculectomy, tube shunts, minimally invasive glaucoma surgery, or MIGS)
• Lifestyle modifications

Glaucoma medications are typically covered under Medicare Part D. Surgical procedures are covered under Part B (outpatient) or Part A (if requiring hospital admission).

African American Glaucoma Risk

Elevated Prevalence and Severity

African Americans face meaningfully elevated glaucoma risk compared to non-Hispanic white Americans, including:

• A higher prevalence of primary open-angle glaucoma
• Earlier age of onset
• More severe progression (greater visual field loss at presentation)
• Higher rates of blindness from glaucoma
• Higher rates of normal-tension glaucoma

For up-to-date prevalence statistics, consult peer-reviewed epidemiological literature and the National Eye Institute glaucoma data summaries.

Implications for Georgia

Georgia has a substantial African American population, larger as a share of state population than the U.S. average. This translates to:

• A large African American Medicare-eligible population
• High volume of beneficiaries qualifying for annual glaucoma screening under the African American age 50+ category
• Particular importance of systematic screening implementation in Georgia

Healthcare Disparities

African Americans face documented healthcare disparities in glaucoma care:

• Lower screening rates
• Later diagnosis
• Less aggressive treatment
• Worse outcomes

Systematic Medicare glaucoma screening implementation can help address these disparities by providing low-marginal-cost access (beyond standard Part B cost-sharing) for the at-risk Medicare population.

Major Georgia Eye Care Providers

Emory Eye Center

Emory Eye Center in Atlanta is an academic eye care center with comprehensive services including:

• Comprehensive ophthalmology
• Glaucoma subspecialty service
• Cornea and refractive surgery
• Retina subspecialty
• Pediatric ophthalmology
• Oculoplastics
• Neuro-ophthalmology
• Optometry services

The Emory Glaucoma Service provides advanced diagnostic and surgical management for complex glaucoma cases.

Wellstar Eye Care

Wellstar Eye Care provides eye care services across the Wellstar Health System's metropolitan Atlanta and north Georgia hospitals. Services include comprehensive ophthalmology, optometry, and subspecialty referral.

Piedmont Eye Center

Piedmont Healthcare provides eye care services through its hospital-based ophthalmology and affiliated optometry network. Services include comprehensive eye examinations, glaucoma management, and surgical care.

Northside Hospital Ophthalmology

Northside Hospital provides eye care services through affiliated ophthalmology and optometry practices throughout metropolitan Atlanta.

Augusta University Eye Institute

Augusta University Medical Center provides academic eye care for east Georgia. The Augusta University Ophthalmology Department includes glaucoma, retina, cornea, and other subspecialties.

Other Georgia Eye Care Resources

Additional Georgia eye care resources include:

• Numerous independent optometry practices throughout Georgia
• Hospital-based ophthalmology departments at regional medical centers
• Retail optometry settings (Walmart Vision Center, Target Optical, Costco Optical, LensCrafters, America's Best)
• Federally Qualified Health Center (FQHC) on-site or contracted eye care
• Mobile vision services in some rural counties

Worked Examples

Example 1: African American Age 55 in Atlanta, Annual Screening

Mr. Jackson, a 55-year-old African American Atlanta resident, became Medicare-eligible under disability. At his Annual Wellness Visit, the provider notes he qualifies for annual glaucoma screening under the African American age 50+ category and has not had an eye examination in 18 months.

Referral: The primary care provider refers Mr. Jackson to an Atlanta optometrist accepting Medicare assignment.

Examination: The optometrist performs the dilated eye examination with IOP measurement, slit-lamp biomicroscopic examination of the optic nerve, and visual acuity assessment.

Billing: The optometrist bills HCPCS G0117 with ICD-10 codes documenting the qualifying high-risk status (African American with no prior glaucoma diagnosis).

Coverage: Medicare pays its standard preventive coinsurance share of the approved amount; Mr. Jackson pays the beneficiary coinsurance after his Part B deductible is met. His Medicare Supplement Plan G covers the coinsurance.

Results: Normal screening findings. The optometrist recommends annual follow-up examination. Mr. Jackson will be eligible for the next covered screening approximately 12 months from this examination date.

Example 2: Diabetic Beneficiary Glaucoma and Retinopathy Combined Eye Exam

Mrs. Davis, a 68-year-old Marietta resident with type 2 diabetes, attends her annual diabetic eye examination at a Wellstar ophthalmology practice. The ophthalmologist performs a comprehensive eye examination that addresses both diabetic retinopathy and glaucoma screening.

Examination: Dilated fundus examination, IOP measurement, optic nerve assessment, fundus photography for diabetic retinopathy screening, slit-lamp biomicroscopic examination.

Billing: The ophthalmologist bills:

• Comprehensive ophthalmologic exam (CPT 92014) with diabetes-related ICD-10 (diagnostic encounter for diabetic retinopathy)
• HCPCS G0117 glaucoma screening with diabetes ICD-10 (preventive screening for glaucoma)

Coverage: The diabetic retinopathy assessment is covered under standard Part B with Mrs. Davis's coinsurance applying. The glaucoma screening is also covered under standard Part B with separate cost-sharing. Mrs. Davis's Medicare Supplement covers the coinsurance.

Results: Mild non-proliferative diabetic retinopathy noted; glaucoma screening normal. The ophthalmologist recommends continued annual examinations and tight diabetes control. Mrs. Davis qualifies for annual glaucoma screening under the diabetes category.

Example 3: Family History-Based Screening

Mr. Thomas, a 67-year-old Augusta resident whose father had advanced glaucoma requiring trabeculectomy in his 70s, qualifies for annual glaucoma screening under the family history category. He visits his Augusta University Eye Institute optometrist for annual screening.

Examination: Dilated eye examination, IOP measurement, and optic nerve assessment showing borderline cupping.

Billing: HCPCS G0117 with ICD-10 documenting family history of glaucoma.

Coverage: Standard Part B coverage with coinsurance.

Follow-up: Given borderline cupping and family history, the optometrist refers Mr. Thomas to the Augusta University Glaucoma Service for comprehensive evaluation including visual field testing and OCT of the optic nerve. These follow-up diagnostic tests are covered under standard Part B rules (not the screening benefit) at separate cost-sharing.

Example 4: Hispanic American Age 66 in Gwinnett County

Mrs. Hernandez, a 66-year-old Hispanic American Gwinnett County resident, qualifies for annual glaucoma screening under the Hispanic American age 65+ category. Her primary care provider at a Hispanic community health center refers her to a Spanish-speaking optometrist.

Examination: Dilated eye examination, IOP measurement (within the normal range bilaterally), and slit-lamp biomicroscopic examination of the optic nerve (normal cup-to-disc ratios).

Billing: HCPCS G0117 with ICD-10 documenting Hispanic American age 65+ eligibility.

Coverage: Standard Part B coverage with coinsurance. Mrs. Hernandez's Medicare Advantage plan applies plan-specific cost-sharing.

Results: Normal screening. The optometrist provides Spanish-language patient education materials about glaucoma and recommends annual follow-up.

Example 5: Abnormal Screening Referral to Ophthalmology

Mrs. Wright, a 70-year-old African American Macon resident, attends her annual glaucoma screening at her optometrist's office. The screening reveals elevated IOP bilaterally and enlarged cup-to-disc ratios.

Screening Outcome: Abnormal, concerning for glaucoma.

Billing: HCPCS G0117 with documentation of abnormal findings.

Referral: The optometrist refers Mrs. Wright to an Atlanta ophthalmologist for comprehensive glaucoma evaluation including:

• Repeat IOP measurements
• Visual field testing (Humphrey perimetry, CPT 92083)
• Optical coherence tomography (OCT, CPT 92133)
• Gonioscopy (CPT 92020)
• Pachymetry (CPT 76514)

Coverage: The diagnostic workup at the ophthalmologist's office is covered under standard Part B rules with Mrs. Wright's standard cost-sharing.

Diagnosis: Following workup, Mrs. Wright is diagnosed with primary open-angle glaucoma and started on prostaglandin analog eye drops (covered under her Part D plan). Ongoing diagnostic and management eye care continues under standard Part B rules.

Example 6: Rural Southwest Georgia Eye Care Access

Mr. Robinson, a 72-year-old African American resident of Cuthbert in Randolph County (rural southwest Georgia), needs annual glaucoma screening. His nearest optometrist is in Albany (approximately 50 miles away).

Access Challenge: Rural southwest Georgia has limited local eye care provider density. Mr. Robinson coordinates transportation through a family member for the Albany appointment at a local optometry practice.

Examination: Dilated eye examination with IOP measurement and optic nerve assessment.

Billing: HCPCS G0117 with ICD-10 documenting African American age 50+ eligibility.

Coverage: Standard Part B coverage with coinsurance.

Access Considerations: The 50-mile travel represents a significant rural Georgia access challenge. Some Georgia health systems and community organizations support mobile eye screening services in underserved areas; Prevent Blindness Georgia and similar organizations also support outreach. Federally Qualified Health Centers in rural Georgia sometimes offer or coordinate eye care services.

Results: Normal screening. Mr. Robinson plans annual follow-up at the Albany optometry practice.

Provider Best Practices

1. High-risk category documentation: Document the qualifying high-risk category clearly in the medical record to support claim adjudication.
2. Annual scheduling: Track the last screening date and schedule the next annual screening to ensure systematic adherence.
3. Comprehensive eye examination integration: For diabetic beneficiaries, integrate glaucoma screening with diabetic retinopathy examination.
4. Referral coordination with primary care: Establish referral relationships with primary care practices to enable AWV-driven referrals.
5. Patient education on cost-sharing: Inform beneficiaries about standard Part B cost-sharing for glaucoma screening (unlike many zero-cost preventive services).
6. Abnormal finding workflow: Establish a clear referral pathway for abnormal screening to ophthalmology.
7. Visual field and OCT availability: Plan for follow-up diagnostic testing when abnormal screening identifies further evaluation needs.
8. EMR templates: Use standardized screening templates for consistent documentation.
9. High-risk population outreach: Coordinate with community health and AWV providers to reach at-risk populations.
10. Spanish-language access: Provide bilingual services for Hispanic American beneficiaries.
11. African American outreach: Implement targeted outreach given elevated glaucoma risk in African Americans.
12. Rural access: Coordinate with mobile services or regional facilities for rural beneficiaries.
13. Continuing professional education: Stay current on glaucoma diagnosis and management evidence.
14. Medicare assignment: Accept Medicare assignment to maintain protected pricing.

Common Issues and Resolutions

1. Beneficiary surprised by cost-sharing: Beneficiaries may expect zero cost-sharing common with other preventive services. Resolution: clearly explain that glaucoma screening has standard Part B cost-sharing because USPSTF Grade A/B is not in place.
2. Frequency violation: A screening performed before the required interval since the prior covered screening may be denied. Resolution: verify the last screening date before scheduling.
3. Provider not eligible: Glaucoma screening must be by an optometrist or ophthalmologist. Resolution: ensure the provider type is appropriate.
4. State licensure issues: The provider must be state-licensed. Resolution: verify Georgia state licensure status.
5. G0117 vs G0118 coding: Code selection depends on whether the optometrist or ophthalmologist personally performs the service versus supervises it. Resolution: use the correct code based on actual service delivery.
6. Combined diabetic eye exam coding: Combining glaucoma screening with a comprehensive eye exam can raise coding questions. Resolution: bill each service appropriately with separate codes when clinically justified.
7. Missing high-risk documentation: Without clear high-risk documentation, claims may be denied. Resolution: document the qualifying category in the medical record.
8. Abnormal screening follow-up gaps: Beneficiaries may not follow through on referral. Resolution: implement workflow to track abnormal screening referrals.
9. Rural access barriers: Resolution: coordinate with mobile services, regional facilities, and transportation support.
10. Beneficiary unaware of eligibility: Many high-risk beneficiaries do not know they qualify. Resolution: AWV-driven primary care education and referral.
11. Confusion with diabetic retinopathy examination: Beneficiaries may conflate the two. Resolution: clear patient education about distinct purposes.
12. EMR does not flag eligibility: Resolution: implement EMR reminders for eligible beneficiaries.
13. Insurance card or coverage issues: Resolution: verify Medicare coverage at time of service.
14. Medicare Advantage coverage variations: Plan-specific cost-sharing may differ. Resolution: confirm coverage with the plan in advance.

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