Print FriendlyPrint | Share

CPT Code: 92250  Region: 24

States covered:  Kentucky, Ohio

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.


Limitations:

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 (CPT codes 92250 and 92228) are bilateral services on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee.
  • 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.
  • Remote imaging for detection of retinal disease (CPT code 92227) is considered screening and will be denied as non-covered.
  • Provision of fundus photography, by providers other than opthalmologists 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.  For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

2.  The diagnosis code(s) must best describe the patient’s condition for which the service was performed.  For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

3.  All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

4.  CPT code 92250 describes a service that is performed bilaterally. Modifier 50 is never appropriate with these codes. Modifiers LT and RT should only be used if a unilateral service is performed.

5.  CPT code 92250 is a global service, which include a professional and a technical component.  The components should be reported with modifiers 26 or TC as appropriate, if the entire global service is not performed.

6.  Acceptable places of service for the global service are office, assisted living facility, urgent care, nursing facility for patients in a Part B stay, and independent clinic.

7.  The technical component may be billed in office, assisted living facility, urgent care, nursing facility for patients in a Part B stay, independent clinic, federally qualified health center, and rural health clinic.

8.  The professional component may be billed in office, assisted living facility, urgent care, inpatient hospital, outpatient hospital, nursing facility for patients in a Part B stay and independent clinic.

UTILIZATION GUIDELINES

This Medicare carrier has no specific utilization guidelines for fundus photography.  In the absence of specific utilization guidelines, optometrists/ophthalmologists should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of practice.

CATEGORIES