Coding & Reimbursement

Clarifying Fundus Photography

By Suzanne L. Corcoran, COE

Fundus photography is a diagnostic test that has been available to ophthalmologists for many years and continues to be valuable. Because questions about Medicare rules still persist, this Q&A will attempt to clear up the confusion.

Q. Does Medicare cover fundus photography?

Sometimes. Medicare covers fundus photography if the patient presents with a complaint that leads you to perform this test or as an adjunct to management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then it is not covered (even if disease is identified). Also, this test is not covered if performed for an indication that is not cited in the local coverage determination (LCD) policy. Check with your carrier for specific coverage limitations.

Q. What CPT code should we use to describe this test?

CPT code 92250 (Fundus photography with interpretation and report) best describes this test.

Further, 92250 is defined as "bilateral" so reimbursement is for both eyes. The 2007 national Medicare Physician Fee Schedule allowable is $72.01 (for participating physicians). This amount is adjusted in each area by local indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Q. What documentation is required to support this claim?

In addition to the photos or proof that digital images exist, the chart should contain:

► an order for the test with medical rationale
► the date of the test
► the reliability of the test (e.g., cloudy due to cataract)
► the test findings (e.g., hemorrhage)
► a diagnosis (if possible)
► the impact on treatment and prognosis
► the signature of the physician

A form suitable for documenting the interpretation of fundus photos and other tests is available on our Web site.

Q. Is the physician required to be present during the test?

Not according to Medicare. Under the Medicare program standards, this test only needs 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. How often may this test be repeated?

There are no published limitations for repeated testing. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from Medicare and other third-party payers.

Q. What is the frequency of fundus photography in the Medicare program?

Medicare utilization rates for claims paid in 2005 show that fundus photography was performed in 6% of all office visits by ophthalmologists. That is, for every 100 exams and consultations performed on Medicare beneficiaries, Medicare paid for this service six times.

Q. Is fundus photography bundled with any other services?

Yes. According to Medicare's National Correct Coding Initiative (NCCI), 92250 is bundled with ICG (92240) and mutually exclusive with scanning laser ophthalmoscopy (92135).

Q. If Medicare does not cover the test, may we charge the patient?

Yes. Explain to the patient why the test is necessary and that Medicare will likely deny the claim. Ask the patient to assume financial responsibility for the charge; get his or her signature on an Advance Beneficiary Notice (ABN) and submit your claim with modifier GA. 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. OM