Article

Coding & Reimbursement

Get up to speed on fundus photography billing

Fundus photography isn’t a new test, although great advances in the technology continue. Billing rules do change, though, so here is a review.

Q. What is fundus photography?

A. Photographs of the macula, retina and optic nerve, with or without colored filters, are fundus photographs. The posterior pole can be photographed directly through the pupil, with or without mydriasis. Dilation permits sharper and brighter pictures because a larger pupil admits more light. Fundus photographs permit a longer look at the back of the eye than is possible with ophthalmoscopy and aid in evaluating and monitoring disease.

Q. What documentation is required in the medical record to support a claim for fundus photography?

A. In addition to the images, the medical record should include:

  • Order for the test with medical rationale
  • Date of the test
  • The reliability of the test (eg, cloudy due to cataract)
  • Test findings (ie, microaneurysm)
  • Comparison with prior tests (if applicable)
  • A diagnosis (if possible)
  • The impact on treatment and prognosis
  • Physician signature

Note that a physician’s interpretation and report are required; a brief notation such as “abnormal” does not suffice. A form suitable for documenting the interpretation of fundus photos and other tests is available on Corcoran Consulting Group’s website (https://tinyurl.com/srjmj5m ). It may also be adapted for use within an EMR system.

Q. What CPT code is used to report fundus photography?

A. Use CPT code 92250 (Fundus photography with interpretation and report) to report this test.

Q. Is fundus photography covered by Medicare and other third-party payers?

A. Medicare will reimburse you for fundus photography if the patient presents with a complaint that leads you to perform this test as an adjunct to evaluation and management of a covered indication. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, however, the test is generally not covered (even if disease is identified). Also, it is not covered if performed for indications not in the local coverage policy.

Q. What is the reimbursement for 92250?

A. CPT 92250 is defined as bilateral, so reimbursement is for both eyes. The 2020 national Medicare Physician Fee Schedule allowable is $45.83. Of this amount, $23.82 is assigned to the technical component and $22.01 is the value of the professional component (ie, interpretation). These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Fundus photography is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.

Q. What is Medicare’s supervision requirement for fundus photography?

A. Under Medicare program standards, this test requires general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

Q. Is fundus photography bundled with other tests or services?

A. Yes. According to Medicare’s National Correct Coding Initiative (NCCI), the new codes for extended ophthalmoscopy, 92201 and 92202, are bundled with fundus photography and may not be unbundled for any reason. Likewise, the remote screening retinal test, 92227, is bundled with 92250 and may not be unbundled. The technician exam 99211 is bundled with 92250, as it is with most tests. Code 92250 also is mutually exclusive with scanning computerized ophthalmic diagnostic imaging of the posterior segment (92133, 92134).

Q. What is the frequency of 92250 in the Medicare program?

A. Medicare utilization rates for claims paid in 2018 show that fundus photography was associated with almost 10% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service about 10 times. For optometrists, the utilization rate is about 15%.

Q. How often may we repeat this test?

A. Repeat fundus photography is necessitated by disease progression, the advent of new disease or planning for additional surgical treatment (eg, laser). Otherwise, repeated photos of the same, unchanged condition are unwarranted or noncovered.

Q. If coverage is unlikely or uncertain, how should we proceed?

A. Explain to the patient why the test is necessary and that Medicare or another third-party payer will likely deny the claim. Then ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and it may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.

For Part C Medicare (Medicare Advantage or MA), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA plans may have their own waiver forms and are not permitted to use a Medicare ABN form. For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN. OM