Optometry Coding & Billing Alert

Published on Mon Jan 04, 2010 PDF

Question: Our optometrist performs external ocular photography for a Medicare patient with a malignancy on her left eyeball. Is this a covered service?

New York Subscriber

Answer: Based on the patient's diagnosis (190.0,Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid), the photography should be covered -- if your optometrist is taking the photos in an effort to "track or treat" the malignancy. Medicare will typically cover 92285 (External ocular photography with interpretation and report for documentation of medical progress) if the OD is either:

• tracking the progression of the disease or

• checking the effectiveness of a particular course of treatment for the disease.

If your optometrist conducts the photography for either of these purposes, you can report 92285 to Medicare. But if you are unsure about your individual policy, contact your local Medicare carrier before filing the claim.

If your OD performed the photography to "track or treat" the disease, most Medicare payers will deem 92285 medically necessary based on your patient's diagnosis (190.0).

Other diagnoses that many Medicare carriers accept for 92285 include these series:

• 190.x -- Malignant neoplasm of eye

• 364.5x -- Degenerations of iris and ciliary body

• 370.6x -- Corneal neurovascularization.

But not all Medicare carriers observe the same ICD-9 guidelines for 92285. So check with your local carrier if you have any questions.

Cataract note: Medicare will not pay to photograph a cataract (366.xx) since the main way you follow the progression of the cataract is by measuring acuity.

If you have a case that you feel warrants a photo but you're not sure whether the diagnosis supports medical necessity for the insurer, don't be afraid to go ahead and submit. You can always write off the charge later if it is denied.