Ophthalmology and Optometry Coding Alert

"Many ophthalmologists feel its necessary to perform 92250 (fundus photography with interpretation and report) and 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) together. As the descriptors indicate, both codes include an interpretation and report. But some ophthalmologists are asking, if these two procedures are done in connection, why they have to do an interpretation and report of 92250 if they have one for 92235 already in the chart. The short answer is: because CPT says so. Although payers dont always adhere to CPT requirements, in this case they will.

Include Separate Reports

Ophthalmologists should remember these two very important points when documenting reports for both 92250 and 92235:

1. Document medical necessity. If Medicare audits your charts and finds you are performing a fundus photo every time you perform a fluorescein angiogram (FA), they may think you have a standing order in place for the fundus photo, says Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology, based in Santa Barbara, Calif. A standing order is a request, policy or understanding that certain services are to be performed unless there is a specific order not to for the patient. (See box on page 43.) Without documentation of the specific physicians order for each test performed, you lack medical necessity for the service and will not be reimbursed by Medicare, says Duran. Medicare allows standing orders only in extended-care settings such as lengthy hospitalizations or nursing-home care. Even in those settings, Medicare requires that standing orders be checked with the provider(s) who set them on a regular basis to affirm that quality care is being delivered.

2. Document technical and professional components. In the Medicare program, services that have with interpretation and report in their description have relative value units (RVUs), or payment, allocated separately for the testing or technical component of the service, Duran explains. This usually is included in the global payment for the service (professional and technical) rendered by the same provider. It also can be recognized with a -TC modifier (technical component) if only the technical component is being provided. The physician interpretation, or professional component, can be recognized with the -26 modifier (professional component) if the provider is rendering only the interpretation and not providing or billing for the technical component.

When you report the global servicethe CPT code for the testing service without the -TC or -26 modifier attachedyou are reporting that you have performed both the technical and professional component of the service, Duran says. If you do not have documentation of both services in your medical record and bill the global service, you are billing for services not rendered. Repeated billing of [...]