Coding & Reimbursement

Children and Photoscreening

By Suzanne L. Corcoran, COE

A complete eye exam by an ophthalmologist or optometrist skilled in the examination of children, should be performed on all children age 3-4 years. However, many of these children cannot cooperate for visual acuity testing. Ocular photoscreening is an alternative that can be performed by an eye care professional (M.D., D.O., or O.D.), by a lay person with the required skill (e.g., a technician), or by a primary-care physician.

Q. What is photoscreening?

A. Photoscreening is a rapid, efficient, reproducible and highly reliable technique for the early detection of sight-threatening conditions in children, such as strabismus, refractive errors, media opacities and retinal abnormalities. Using this technique, a photograph is produced by a calibrated camera under prescribed lighting conditions, which shows a red reflex in both pupils. A trained observer can identify ocular abnormalities by recognizing certain characteristic changes in the photographed pupillary reflex.

For further information, see also the American Academy of Pediatrics' policy statement, Use of Photoscreening for Children's Vision Screening.

Q. What are the attributes of a screening program?

A. Screening is differentiated from other diagnostic testing by several features.

• Screening is part of a wellness program to check for disease that may otherwise go undetected.

• Screening is not prompted by a patient complaint, symptom, or problem.

• Screening is not required by medical necessity.

Q. How should photoscreening be coded?

A. Effective Jan. 1, 2008, use 99174 (ocular photoscreening with interpretation and report, bilateral) to report this service. Prior to 2008, Category III code 0065T was used to describe this service on claims for reimbursement. CPT further instructs that physicians should not report 99174 in conjunction with 92002 - 92014, 99172 or 99173 (vision screening).

Use diagnosis code V80.2 (special screening for neurological, eye and ear diseases, other eye conditions).

Q. Do health insurance plans cover screening?

A. Sometimes it does, but not usually. As a general rule, routine care, preventative medicine, prophylactic measures and screening are not covered services. Some health plans take the opposite view and encourage patients to maintain their health and have frequent check-ups for early disease detection.

Check the payer's policies before testing.

In the absence of insurance coverage, patients must make a choice about photoscreening. After the benefits of photoscreening have been explained, the patient or parent is advised of the extra charge for the service and may be asked to sign a form acknowledging financial responsibility for a non-covered service.

As a point of reference, Medicare allows approximately $25 for this service. Of course, since this test is performed primarily on children, Medicare is not the usual payer. Medicaid plans vary in their coverage and payment policies.

Q. If photoscreening discovers pathology, will a claim be reimbursed?

A. For those payers who do not cover screening, the results of the photoscreening are immaterial with respect to reimbursement. For most third-party payers, screening is a non-covered service regardless of what is found.

If screening reveals pathology and additional testing is ordered, it is likely covered, as are additional visits for the medical condition. Medically necessary diagnostic tests ordered to evaluate suspected disease are covered services. Reimbursement of your claim is expected, provided that the chart documentation is complete and supportive.

Children who fail either visual acuity testing or photoscreening, or who cannot be adequately screened with either technique after age 42 months, should be referred to an ophthalmologist experienced in the care of children.

Q. What does the chart documentation contain besides the photograph?

A. In addition to the photograph, the chart should contain:

1. the patient's name and date of the test

2. appropriate chart notes about the results, including an interpretation of the test results and a notation of the findings and assessment

3. the signature of the physician. OM