92250_R05

Medical record documentation maintained by the performing physician must indicate the medical necessity of the fundus photography and be available to Medicare upon request.  Office records/progress notes must document the complaint, symptomatology, or reason necessitating the test and must include the examination results/findings.

Photo documentation may be one of the following types: reproducible, slides, prints, digital photography, computerized analysis, or stereo photos.

• Medical record documentation must clearly indicate rationale which supports the medical necessity for performing fundus photography and posterior segment SCODI on the same day on the same eye.  Documentation should also reflect how the test results were used in the patient’s plan of care.
• It would not be considered medically reasonable and necessary to perform fundus photography and posterior segment SCODI on the same day on the same eye to provide additional confirmatory information for a diagnosis or treatment which has already been determined.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

The appropriate ICD-10-CM coded to its highest specificity for the covered procedure must be submitted as the line diagnosis on the claim.

The Relative Value Unit (RVU) amount for this procedure is based on the procedure being performed as a bilateral service.  Therefore, CPT code 92250 should not be billed with site modifiers (RT, LT, or 50).

All services/procedures performed on the same date of service for the same patient by the same provider should be submitted on the same claim.

Reasons for Denials

Fundus photography will not be covered for routine screening or at a frequency that exceeds what is expected in clinical practice.

Fundus photographs are seldom indicated and are rarely appropriate for the diagnosis and management of common retinal disorders, particularly unspecified background retinopathy, hypertensive retinopathy and changes in vascular appearance.

Fundus photography will not be covered if documenting stable or minimal diabetic retinopathy and is inappropriate in diabetic patients who have no clinical retinopathy.  It is also inappropriate in the evaluation of aphakia, iridocyclitis, cataracts and vitreous opacities.

Fundus photography is not covered to document progression of disease if no treatment options are available.

Fundus photography is not a covered service when used to document the absence of pathology (e.g., a normal or healthy fundus) or when the physician elects to incorporate it as a routine procedure.  Routine fundus photography for purposes other than documentation, monitoring, and treatment of a pathological process falls outside the standard of care as medically necessary and is thereby not a covered service.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.  When services are performed in excess of established parameters, they may be subject to review for medical necessity.

GLAUCOMA ASSESSMENT GUIDELINES

These guidelines are used to determine the primary diagnosis: glaucoma suspect or glaucoma and to assign a category of damage for those patients with glaucoma.

Categories of Glaucomatous Damage

Glaucoma Suspect or Glaucoma – Mild Glaucomatous Damage would demonstrate any of the following:

Intraocular Pressure (IOP)

• IOP > 22 mmHg as measured by applanation

Optic Nerve

• Symmetric or vertically elongated cup enlargement, neuroretinal rim intact
• Cup/disc ratio > 0.4
• Optic disc hemorrhage
• Diffuse or focal narrowing or notching of the optic disc rim, especially at inferior or superior poles
• Asymmetrical appearance of the optic disc or rim between fellow eyes that suggest loss of neural tissue

Retina

• Diffuse or localized abnormalities of the retinal nerve fiber layer, especially at inferior or superior poles

Visual Field

• Mild constriction of visual field isopters
• Nasal step peripheral to 20 degrees or small paracentral or arcuate scotoma  

Glaucoma – Moderate Glaucomatous Damage would demonstrate any of the following:

Optic Nerve

• Enlarged optic cup with neuroretinal rim remaining but sloped or pale
• Cup/disc ratio > 0.5 but < 0.8
• Focal optic disc notch with thinning of the neuroretinal rim

Visual Field

• Definite glaucomatous visual field defects
• Arcuate defect
• Nasal step
• Paracentral scotoma
• Constriction of isopters
• Generalized depressions 

Glaucoma – Advanced Glaucomatous Damage would demonstrate any of the following:

Optic Nerve

• Diffuse enlargement of optic nerve cup
• Cup/disc ratio > 0.8
• Wipeout of all or a portion of the neuroretinal rim  

Visual Field

• Severe generalized reduction of retinal sensitivity
• Severe generalized constriction of isopters (i.e., Goldmann I4e, <10 degrees of fixation)
• Absolute visual field defects to within 10 degrees of fixation
• Loss of central visual acuity, with temporal island remaining