Ophthalmology and Optometry Coding Alert

How you handle fundus photography claims today could affect the outcome of your next audit.

Fundus photography, 92250 (Fundus photography with interpretation and report), a highly specialized form of medical imaging, is a common procedure that a technician performs. A fundus camera, which is attached to an ophthalmoscope, is aligned to view the back of the eye. Pictures are then taken of the optic nerve head, vitreous, macula, retina and its blood vessels to document any present pathology.

92250 is in CPT's special ophthalmological services section, which is a compilation of services that practices may report for Medicare in addition to the general ophthalmological services (92002-92014) or E/M services (99201-99499).

Other payers, such as the "Blues," may try to bundle these services. But on the Medicare fee schedule, many of these codes have both a technical component and a professional component and, in CPT, have language that states, "interpretation and report by the physician is an integral part of special ophthalmological services," which sometimes goes unnoticed.

The majority of codes in the special ophthalmological section are for diagnostic tests, i.e., 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2]), 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral), and 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report).

Documenting Your Way to Clean Audits

Though fundus photographs can be used to diagnose certain eye conditions, they are more often used to document a disease process or a diagnosis the physician has already observed. As a result, many ophthalmologists do not comply with the "interpretation and report" component of the code. "They also do not document the order for the photo consistently, thereby placing themselves at risk if they are ever audited," says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy based in Santa Barbara, Calif.

"Even though the payer rarely knows what the documentation looks like at the time they process [a claim] for payment, if the records are ever reviewed as part of an audit, and interpretations are not documented, then the practice will owe money back to the payer at a minimum," adds Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. The practice could even be fined for "billing for services not rendered," a recognized type of billing fraud by the Office of Inspector General (OIG) and an area discussed in the compliance program for physicians, Roberts warns.

Exposing Coding Solutions

The secret to consistent fundus photography reimbursement and staying clear of fraudulent coding is the answer to avoiding most claims problems: thorough documentation. As mentioned above, coders often make the mistake of disregarding the crucial element of interpretation and report because fundus photographs are frequently considered "documentative," not "diagnostic."

In fact, in some practices, "it is common for the ocular photographer to take a fundus photograph when performing fluorescein angiongraphy (FA) or indocyanine-green (ICG) angiography without an order from the physician," Duran says. These "standing orders" performing and billing for a test without a written order from the physician are another type of billing fraud in the Medicare program. "The services of ICG and fundus photo are bundled on the Correct Coding Initiative list, which means Medicare will only pay for the ICG," Duran add, "unless [the fundus photo] is unbundled with the -59 modifier."

You may want to implement a system to ensure that the order and interpretation of the test are documented.

Consider a sticker system to help keep diagnostic test components organized, suggests Michael J. Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J. "Based on my perceived need to increase my documentation standards, as well as time pressures in the daily schedule, I decided that I needed to have a way to insert in the record a lot of stuff quickly and legibly," Yaros says.

His system consists of forms for new exams, intermediate exams, minor procedures, ABNs, hardship waivers, superbills, flowsheets, extended ophthalmo-scopies, retinal lasers, glaucoma lasers and capsulotomies, as well as a template for letters to referring doctors.

Yaros uses stickers for reports for services such as stereo disc photographs, A-scans and gonioscopies. He also has scheduling stickers for cataract surgery, capsulo-tomies, and diabetic and glaucoma lasers. He uses one sticker to order a test, another for the technician's description of the service and her observations, and a third for the physician's own interpretation.

However you decide to improve your reimbursement, experts advise you to choose one method of billing diagnostic tests and stick with it.

One way to bill fundus photography and other "diagnostic" tests is to bill the technical component (92250-TC) and the professional component (92250-26) separately. Because the physician does not always complete the interpretation and report segment of the service immediately, this method can be useful. The technical component can then be billed when the photos are taken or the technical part of the service is performed. The professional component can later be billed when the interpretation and report segment has been documented in the medical record.

A potential downside to separate billing is that it can "get cumbersome and takes a lot of coordination to make sure both segments get billed," says John S. Bell, CEO, CMPE, of Maine Eye Care Associates based in Waterville, Maine. It can also be confusing to your patients, who will receive an explanation of benefits for the day the service was performed and another for when the interpretation was performed. This may lead your patient to believe you are double billing.

The second method for coding diagnostic tests is to wait until the entire test is complete, including the interpretation and report, in which case you would simply use 92250, but again, the date will not coincide with the day the patient was seen.

Coders should be aware that Medicare and most other payers consider fundus photography a bilateral code. Therefore, the bilateral modifier, -50, does not apply when photos are taken of both eyes. Because fluorescein angiography is considered a unilateral code, coders often mistakenly apply the bilateral code to fundus photographs when taken in conjunction with fluorescein angiographs.