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CPT Code: 92250  Region: 02

States covered:  Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin

Title:  Fundus Photography

Category
Special Ophthalmological Services

Description
Fundus photography (includes multi-frame imaging) with interpretation and report

FEE SCHEDULE



PROCEDURE DESCRIPTION

Fundus photography involves the use of a retinal camera to document abnormalities of of the retina and disease processes affecting the eye, in order to follow the progress of such disease.  The test must be used in the medical decision making for the patient.

CLINICAL INDICATIONS

Fundus photography may be indicated to document abnormalities of disease processes affecting the eye, or to follow the progress of such disease.

In order to document a disease process or follow the progress of a disease, photographs and an interpretation and report of the test may be necessary.  Photographs and an interpretation and report of the test may also be necessary to plan treatment for a disease process.

Fundus photography may be used for the diagnosis of conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, glaucoma, multiple sclerosis or other central nervous system anomalies.

Fundus photography may be indicated for examination of the retina in diabetic patients, in whom symptoms of visual disturbances may be present and in whom retinal examination may be unremarkable or normal.

If the study is performed as a screening service, it is not covered by Medicare.

  • All tests must include a written interpretation.  If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary.
  • Fundus photography is not a substitute for an annual dilated examination by a qualified professional (e.g., in diabetic patients).  Fundus photographs taken by a non-eye professional and sent (transtelephonically, via internet, or by other means) to a qualified professional for interpretation are covered for the monitoring and management of active retinal disease.  The interpretation of tests done with remote imaging must be performed by a physician or qualified non-physician practitioner.
  • Provision of fundus photography, by providers other than ophthalmologists or optometrists, as a screening test to facilitate referral to a specialist is contrary to requirements for testing as codified in 42CFR 410.32, and is therefore not covered.  Furthermore, the ordering/performance of fundus photography by eye specialists prior to a face-to-face encounter is similarly not covered or reimbursable.

COVERED DIAGNOSES

ICD-10 Diagnosis Codes



DOCUMENTATION REQUIREMENTS

The patient’s medical record must contain documentation that fully supports the medical necessity for fundus photography as it is covered by Medicare.  This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

A copy of the fundus photographs must be retained in the patient’s medical records.  An interpretation and report of the test must also be included, in addition to the photographs themselves.

The medical record should document whether the pupil was dilated, and which drug was used.

Documentation supporting the medical necessity should be legible, maintained in the patient’s record, and must be available to the carrier upon request.

CODING GUIDELINES

1.  Report fundus photography with CPT code 92250.  This is a bilateral service on the Medicare Physician Fee Schedule database.  When it is medically necessary to photograph both eyes, the procedure is reported on a single service line without the -50, -RT or -LT modifiers and a unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.

2.  If only one eye is photographed, the -52 modifier is appended to the service line to indicate a unilateral service. In addition, the site modifier -RT or -LT should be used when the -52 modifier is used.

3.  Fundus photography requires general supervision by the optometrist/ophthalmologist.

4.  It may be necessary to take a series of photographs at one session to document the patient’s progress.  However, CPT code 92250 should only be reported once for a series of photographs taken at one session.

5.  An eye examination may be reported on the same day as fundus photography and if it is medically necessary.

UTILIZATION GUIDELINES

1.  Fundus photography is usually medically necessary no more than two times per year.

2.  Fundus photography of a normal retina will be considered not medically necessary.

3.  Services exceeding these parameters will be considered not medically necessary.

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