HCPCS code G0117 – Glaucoma screening for high-risk patients

Key takeaways

G0117 is a screening-only code for Medicare Part B patients at high risk of glaucoma who have no existing glaucoma diagnosis.

G0117 applies when the optometrist or ophthalmologist personally performs the screening, and G0118 covers the same screening performed by staff under their direct supervision.

Medicare covers the screening once per 12-month period, and the standard Part B deductible and 20% coinsurance apply.

Every claim pairs Z13.5 with a code for the qualifying risk factor, such as diabetes or Z83.511 for a family history of glaucoma.

Pabau, the practice management platform we build, keeps the patient record, screening note and claim together, so billers can check documentation before submission.

HCPCS code G0117: Quick reference

HCPCS code G0117 reports a Medicare glaucoma screening that an optometrist or ophthalmologist performs personally for a high-risk patient with no glaucoma diagnosis. Medicare Part B covers it once per 12-month period, with the usual deductible and 20% coinsurance. The table sums up the descriptor, payer, frequency rule and companion code.

Official descriptor and code family

G0117 belongs to the HCPCS Level II G-code series, which CMS maintains for Medicare-covered services that have no exact CPT equivalent. The CMS HCPCS overview describes G-codes as codes CMS creates for national benefit programs outside the AMA CPT system.

The glaucoma screening benefit comes from the Benefits Improvement and Protection Act of 2000 (BIPA), effective January 1, 2002, and NCD 80.1 governs it. Two codes report the same screening. G0117 applies when the optometrist or ophthalmologist performs it personally, and G0118 applies when staff perform it under the OD or MD’s direct supervision.

G0117 is strictly a preventive screening code. It cannot report an exam for a patient who already has a confirmed glaucoma diagnosis, and doing so is miscoding under CMS policy. Bill those patients with a CPT eye exam code from 92002 to 92014, such as 92014, plus the relevant glaucoma ICD-10 code.

What G0117 glaucoma screening includes and excludes

The Medicare benefit under G0117 covers a defined screening encounter rather than an open-ended eye exam. Knowing where it stops keeps the claim from overlapping with services billed separately.

What is included

• A dilated eye examination with an intraocular pressure measurement
• Direct ophthalmoscopy or a slit-lamp biomicroscopic examination
• Clinical evaluation of risk factors and documentation of the high-risk qualifier

What is excluded

• Refraction or prescription of corrective lenses (Medicare does not cover routine refraction)
• Diagnostic workup or treatment for confirmed glaucoma (use CPT codes with glaucoma ICD-10 codes)
• A comprehensive eye exam under 92002 to 92014 on the same date without separately documented medical necessity
• Gonioscopy (CPT 92020) or visual field testing (CPT 92083), unless a distinct, separately documented medical reason exists

High-risk patient criteria for G0117

Both the patient and the provider must meet eligibility requirements for a G0117 claim to process. CMS NCD 80.1 defines the high-risk criteria, and those definitions govern what the medical record must show.

A patient qualifies as high-risk under NCD 80.1 if they meet at least one of these criteria:

CMS defines the race and age criteria in law, so document exactly what the NCD requires. A note that says “elderly patient at risk” without race or ethnicity and age can fail medical necessity review.

G0117 vs G0118: Who performs the screening

G0117 and G0118 describe the same clinical screening. The difference is who performs it: the OD or MD personally for G0117, or staff under the OD or MD’s direct supervision for G0118. Choosing the code that doesn’t match the chart is a common cause of G0117 denials.

When technicians perform part of the screening, the note should record who did each step and that the OD or MD directly supervised it. That record decides whether the claim goes out as G0117 or G0118, whatever the staff member’s job title.

Medicare coverage rules and frequency limits

Medicare Part B covers glaucoma screening under G0117 once per 12-month period. The window counts full months, not days: at least 11 full months must pass after the month of the last paid screening. A patient screened in March 2025 is not eligible again until March 2026.

Build these coverage rules into your billing workflow, and confirm them through insurance eligibility verification before the encounter:

• No physician referral required. Medicare covers G0117 without a written order from another provider. The optometrist or ophthalmologist may start the screening directly.
• No prior authorization required for most Medicare Administrative Contractor (MAC) jurisdictions under NCD 80.1.
• Standard cost-sharing applies. The Medicare Part B annual deductible and 20% coinsurance apply. Some other preventive benefits, such as colorectal cancer screening, carry zero cost-sharing.
• MAC Local Coverage Determinations (LCDs) may add requirements. Individual MACs can impose extra documentation or eligibility conditions beyond NCD 80.1. Check your jurisdiction’s LCD before assuming the NCD alone governs your claims.
• ABN required when coverage criteria are not met. If the patient doesn’t meet the high-risk criteria but wants the screening, issue an Advance Beneficiary Notice of Noncoverage (ABN) before the encounter. Append modifier GA when a signed ABN is on file, and GZ when none was obtained.

Required ICD-10 diagnosis codes for G0117

Every G0117 claim must carry at least one ICD-10-CM code that supports the patient’s high-risk status. A missing diagnosis code is a leading denial cause. Check the codes below against the CDC ICD-10-CM tool for the current fiscal year, because codes are updated annually.

Use Z13.5 as the primary code for the screening encounter. Pair it with the code for the qualifying risk factor, such as diabetes or family history. Z13.5 alone doesn’t show that the patient meets a CMS high-risk criterion, so it can draw a medical necessity denial.

Documentation requirements for G0117 claims

Documentation is the strongest defense a G0117 claim has in an audit. Consistent billing compliance starts with knowing what the clinical note must show before the claim leaves the practice. Each element below matches a medical necessity checkpoint that MACs apply in post-payment audits.

• High-risk qualifier identified. The note must state which CMS criterion the patient meets (diabetes, family history, or the race and age criterion). A generic “patient is at risk for glaucoma” statement won’t hold up in an audit.
• Screening components performed. Document each element completed: intraocular pressure findings (values and laterality) and ophthalmoscopy or slit-lamp findings (cup-to-disc ratio, nerve fiber layer appearance).
• No established glaucoma diagnosis. The note should show this is a screening for a patient without a confirmed glaucoma diagnosis. A note that references ongoing glaucoma treatment leaves the G0117 claim indefensible.
• Plan and follow-up disposition. Document whether findings are within normal limits or need further workup. If the screening finds something that needs a diagnostic evaluation, bill the follow-up visit with the appropriate CPT exam code.
• Who performed the screening. G0117 requires the OD or ophthalmologist to perform the screening personally. A technician-performed screening under the OD or MD’s direct supervision is billed as G0118, so the note must name who did the work.

Reimbursement and place of service

Medicare sets G0117 reimbursement each year through the Medicare Physician Fee Schedule (MPFS). Rates vary by geographic practice cost index and differ between facility and non-facility settings. Use the CMS Physician Fee Schedule lookup to find the current allowed amounts for G0117 in your MAC jurisdiction. Published static figures go stale after each January 1 update.

Place of service codes accepted for G0117 billing:

Modifier use on G0117 claims follows standard Medicare rules. When an evaluation and management (E/M) visit is billed on the same date, modifier 25 may go on the E/M code. It signals a significant, separately documented E/M service. Document the E/M’s medical necessity in a separate section of the note, and check your MAC’s LCD for local modifier guidance.

Common billing errors and claim denial reasons

Denied G0117 claims almost always trace back to one of six causes. Proactive denial management means building a check for each one into the billing workflow, so fewer rejections need reworking later.

• Patient does not meet high-risk criteria. This is the most common denial. If the chart doesn’t document one of the four CMS criteria, the claim has no medical necessity support. Train schedulers to confirm the risk factor before the encounter.
• Frequency limit exceeded. Billing G0117 for the same patient before 11 full months have passed since the last paid screening triggers an automatic denial. Check the payer’s eligibility response for the date of the last paid screening.
• Wrong code for who performed the screening. Billing G0118 when the OD or MD screened the patient personally, or G0117 when a supervised technician did, misreports the service. Confirm who performed the screening in the note before submitting.
• Missing or incorrect ICD-10 code. Claims with only Z13.5 and no supporting risk-factor code often fail medical necessity edits. Always pair Z13.5 with the qualifying diagnosis code, such as E11.x or Z83.511.
• G0117 billed for a patient with confirmed glaucoma. A claim for a patient whose chart holds a confirmed glaucoma diagnosis (H40.1x to H40.9x) will be denied. Use the appropriate CPT exam code for that encounter.
• No ABN issued before a non-covered screening. Without an ABN, you cannot bill the patient after Medicare denies a screening that didn’t meet the high-risk criteria. Issue the ABN and get it signed before the service. Append modifier GA when a signed ABN is on file, and GZ when none was obtained.

When to use G0117 vs eye exam CPT codes

The choice between HCPCS code G0117 and a CPT eye exam code (92002 to 92014) comes down to four checks, taken in order. The first check that stops you decides how the visit is billed.

The table below adds the less common scenarios, including a same-day E/M visit and visual field testing billed on its own.

How Pabau supports clean G0117 claims

Each denial cause above starts before the claim is built. A risk criterion nobody recorded, an unchecked screening date or a note that doesn’t name who performed the exam all come back later as rework.

Pabau’s claims management software sits in the same system as the patient record, treatment notes and invoicing. Billers can read the screening note and the patient’s history next to the charge, then submit and track the claim without switching tools.

• One patient record. Risk factors, appointment history and diagnoses sit in the record the biller reads before coding.
• Forms and note templates. Intake forms and treatment notes can include fields for the NCD 80.1 criterion and who performed the screening.
• Claims tracking. Submitted claims and payer remittances are matched in one view, so denied or unpaid claims are easy to spot.

Building these checks into each step of the billing workflow gets more G0117 claims through as a clean claim on first submission.

Keep G0117 claims clean from the first submission

Pabau keeps the patient record, screening note and claim in one system. Your billers can check eligibility and documentation before a G0117 claim goes out. See how it works for eye care practices.

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Conclusion

G0117 rewards the practices that settle eligibility before the patient sits down. Confirm the diagnosis status, the NCD 80.1 risk criterion and the last paid screening date at booking. That handles four of the six denial causes before the exam starts, including the ABN decision.

The other two causes live in the note. Record who performed the screening, and pair Z13.5 with the qualifying diagnosis code. A slightly longer intake costs less than reworking a denied Medicare claim.

With the patient record, screening note and claim in one system, those checks become part of the visit. Book a demo to see how Pabau supports Medicare screening claims for eye care practices.

Continue your research

Billing a technician-performed screening? HCPCS code G0118 covers the supervised version of the same glaucoma screening.

Following up a screening with a full exam? CPT code 92012 explains billing the intermediate exam for an established patient.

Need guidance on handling claim denials systematically? Denial management in healthcare covers the workflow steps to reduce denial rates across your billing team.

Want to understand the full claims submission process? What is medical billing walks through the process from charge capture to payment posting.

Looking to verify patient eligibility before encounters? Insurance eligibility verification explains how to check coverage status and benefit limits before the patient arrives.

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