Ophthalmology and Optometry Coding Alert

Hint: Watch your diagnosis codes every time you report 92250.

Fundus photography is one of the most commonly-performed - and least invasive - diagnostic tests that eye care professionals use to help evaluate patients' eye health. Unfortunately, it's also one of the most misunderstood services, because payer policies can differ widely on how to report it.

We've rounded up a few quick facts that can help guide your fundus photography reporting.

1. Medicare Has No National Coverage Determination on This Service

CMS often publishes national coverage determinations (NCDs) to share the agency's nationwide coverage regulations for a particular code or service. Unfortunately, CMS has not yet published an NCD that discusses the coverage criteria for 92250 (Fundus photography with interpretation and report).

In the absence of an NCD, you should check with your local payer (either private or government-based) to find out the policy provisions. Many insurers, including Aetna, Blue Cross/Blue Shield, Palmetto GBA and First Coast Service Options, publish their local coverage determinations (LCDs) online to describe the criteria under which this code is payable. Refer to this document when applicable, and if you can't find it, contact your payer for specifics.

2. In Some Cases, It's Covered in the Absence of Disease

Although not all payers will reimburse you for the same diagnoses, some insurers will cover fundus photography even if the patient hasn't been diagnosed with a chronic eye condition such as retinopathy or macular degeneration.

"You can get paid to take a picture of a normal retina, if there are visual disturbances and other disease processes that warrant the medical necessity of the photos," says Gina Vanderwall, OCS, CPC, CPPM,  financial counselor with Finger Lakes Ophthalmology in Canandaigua, New York. "Our MAC does, however, clearly state that the test must be used in the medical decision-making for the patient."

For example, the Blue Cross/Blue Shield of North Carolina policy states, "Fundus photography should aid in making a clinical decision." Therefore, if you report the fundus photography in a patient without an established eye condition, make sure your diagnosis codes back up the fact that the physician is using the photography in his or her clinical decision-making.

Instead of reporting a diagnosis code for a normal eye screening (for which fundus photography is almost never covered), you'll bill the code for the symptoms that prompted the photographs. For example, Aetna covers this service for patients whose visual evoked potential test is abnormal, and you'd report that with R94.112 (Abnormal visually evoked potential [VEP]).

3. You Typically Can't Report It at Each Visit

Most payers will only reimburse you for 92250 once or twice a year. "Repeat studies by the same physician more than once per year would generally not be expected unless other clinical indications exist to justify the study," notes the policy of Part B payer First Coast Service Options.

What would justify more than once a year? First Coast addresses that as well. "Fundus photos may be of value in the documentation of rapidly evolving diabetic retinopathy. In the absence of prior treatment, studies would not generally be performed for this indication more frequently than every six months," the MAC says.

However, slower disease processes like glaucoma wouldn't necessarily warrant that kind of frequency, and First Coast only covers 92250 annually in those cases.

4. You Can Report 92250 With Eye Codes Or E/M Services

First Coast's policy states, "fundus photography is considered medically reasonable and necessary when it is furnished by a qualified optometrist or ophthalmologist in the course of the evaluation and management of a retinal disorder or another condition that has affected the retina as outlined above."

In line with this statement, you should be able to collect for both the evaluation and management and the fundus photography during the same session, because the Correct Coding Initiative (CCI) does not have any bundles that preclude you from reporting the eye exam codes (92002-92014) or the outpatient E/M codes (99201-99215) with the fundus photography code.

5. Avoid 92250 With SCODI Unless Warranted

One service you probably can't regularly report with fundus photography is SCODI. This service, reported with 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) and 92134 (... retina), is considered by the Correct Coding Initiative (CCI) to be mutually exclusive with 92250.

CCI bundles 92133 and 92250 with a "1" modifier indicator, which indicates you may separately report them, when appropriate, using a modifier such as 59. For example, you can use modifier 59 (Distinct procedural service)  when the physician performs the services on different eyes or for conditions that warrant both on the same eye, such as hemangioma (D18.09). Clear documentation is essential in the event of a payer review.