Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 14, 2006 PDF

Hint:  Don't let a lack of supporting documentation cloud your chances for reimbursement

Question: Optometrists often take fundus photographs (92250, Fundus photography with interpretation and report) in tandem with other diagnostic procedures to document a disease process or follow the progress of a disease. But, when the physician takes fundus photographs on the same day he performs an HRT test, can you bill for both?

Answer: The rules are strict regarding fundus photography with scanning laser imaging such as OCT, HRT or GDx. The National Correct Coding Initiative (NCCI) bundles 92250 and 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) as a mutually exclusive pair, says Jeri O'Connell, CPC, clinical coder at the Massachusetts Eye and Ear Infirmary in Boston. The bundle is marked with a modifier indicator of "1," meaning you may be able to report the codes together by appending a modifier to 92135, as long as your documentation supports the necessity of both.

Experts warn: Many carriers, including Palmetto, Empire (the Part B carrier for New Jersey and part of New York), and HealthNow (upstate New York), have Local Coverage Determinations (LCDs) for 92135 explicitly saying that 92250 "would generally not be necessary with SCODI. When needed the same day, documentation must support the procedures."

Example: An optometrist is monitoring a patient with different chronic conditions. He performs a scanning laser test (92135) to check on the progression of glaucoma and takes fundus photographs (92250) to track changes in diabetic retinopathy. In this case, the physician must carefully assign the diagnosis to each of the tests, and documentation in the medical record must support the medical necessity for each test. You may also want to have the patient sign an advance beneficiary notice (ABN) in case the carrier denies the claim.

The bottom line: Reporting fundus photographs can pay off. In 2003, Medicare allowed over 1.5 million charges for fundus photography, reimbursing eye practices over $100 million.