Optometry Coding & Billing Alert

Published on Sun Sep 26, 2010 PDF

Question: When is it appropriate to bill for extended ophthalmoscopy and fundus photographs on the same day?

Utah Subscriber

Answer: Carriers have different rules regarding extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and fundus photography (92250, Fundus photography with interpretation and report). While not bundled in NCCI, these two codes represent potentially redundant procedures. There are some carriers that bundle the payment for fundus photography into the payment  for the extended ophthalmoscopy. Check your carrier for an LCD; if the carrier doesn't state otherwise, you should be able to bill both separately without modifiers.

Tip: Many optometrists only report 92225 and 92250 together when they can document a change in the optic disk or retina or a change in the visual fields if all is normal. Many LCDs support this strategy. For example, Regence Blue Cross and Blue Shield of Utah's policy states, "Fundus photographs are not medically necessary simply to document the existence of a condition. Photographs are medically necessary to establish a baseline to judge later if a disease is progressive."

Photographing a patient to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy, then comparing that photograph to the patient's clinical appearance four months later, would be acceptable, Regence says.