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CPT Code: 92250  Region: 37

States covered:  General guidelines if your state does not have a local coverage determination

Title:  Fundus Photography

Category
Special Ophthalmological Services

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

DISCLAIMER

This Medicare carrier does not have a local coverage determination (LCD) for fundus photography.  The policy presented is provided to serve as a sample for how other carriers allow the procedure to be billed and coded. It is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.

FEE SCHEDULE



PROCEDURE DESCRIPTION

Fundus photography involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve.  The resultant images may be either photographic or digital and become part of the patient’s permanent record.  Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated.

CLINICAL INDICATIONS

1. Identification and/or follow-up glaucoma suspect with evidence of the following:

  • Increase in intraocular pressure
  • Asymmetric intraocular pressure measures greater than 2-3 mmHg between the two eyes
  • Optic nerves suspicous for glaucoma

a) Asymmetrical cupping
b) Disc hemorrhage
c) An absent or thinned temporal neuroretinal rim

2. Identification and/or follow-up for glaucoma

3. Identification and/or follow-up for disorders of the vitreous

  • Assessment of the vitreous degeneration, hemmorhage, opacities and prolapse

4. Identification and/or follow-up for disorders of the optic

  • Evidence of a pale or swollen optic nerve
  • Optic nerve dystrophies and anomalies

5. Identification and/or follow-up for neuro-ophthalmic disease

  • Assessment of benign and malignant neoplasm

6. Identification and/or follow-up for disorders of the retina

  • Assessment of vascular disorders of the retina and choroid
  • Assessment of disorders and dystrophies of the retina and choroid
  • Assessment of macular degeneration and degeneration of the posterior pole

7. Identification and/or follow-up for systemic disease

  • Diabetes
  • HIV
  • Marfan Syndrome
  • Multiple Sclerosis
  • Sickle Cell
  • Vogt-Koyanagi Syndrome

8. Identification and/or follow-up for patients on high-risk medication

  • Steroids

9. Identificaion and/or follow-up for eye injury

  • Foreign body penetration of anterior and posterior pole

COVERED DIAGNOSES

ICD-10 Diagnosis Codes



DOCUMENTATION REQUIREMENTS

1.  The medical record should clearly indicate the condition being evaluated and the primary diagnosis should support the medical necessity of the testing.

2.  The medical record should have a current, pertinent history and physical examination recorded.  All progress notes describing and supporting the primary diagnosis should be included in the medical record.  The record should include the optometrist/ophthalmologist responsible for and providing the care of the patient.

3.  Current and past fundus photographs should be maintained in the patient’s medical record with an interpretation and report.

4.  Documentation must be made available to Medicare 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

Fundus photography is usually not medically necessary if used for routine screening or to document the absence of pathology or the existence of a condition.  Fundus photography should aid in the clinical decision-making and should not be used to document the existence of a condition to enhance the medical record.

This Medicare carrier has no specific utilization guidelines for fundus photography when the primary diagnosis is a glaucoma suspect or glaucoma, disorder of the vitreous, optic nerve, a neuro-ophthalmic disease, retina, a systemic disease, a high-risk medication or an eye injury.

In the absence of specific utilization guidelines, optometrists should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of optometric practice.

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