Coding & Reimbursement

External Photography Puzzles

By Suzanne L. Corcoran, COE

External photography can be a useful tool to the ophthalmologist, although the Medicare rules on billing can sometimes be confusing. Here is my attempt to clear them up for you.

Q. Does Medicare cover external photography?

A. Sometimes. The key points that warrant coverage include:

• The photographs provide additional information not obtained during the exam.
• The photographs aid in diagnosis and treatment of a disease or condition.
• The photographs are taken to assist in assessing disease progression.

Photographs that are taken merely to document disease are typically treated as an incidental service and not accorded separate reimbursement.

Most Medicare LCDs contain a variety of valid diagnoses for external photos. The lists vary by contractor, but usually include diagnoses related to external and anterior segment diseases involving the lids, lacrimal system, cornea, conjunctiva, anterior chamber and iris.

Q. What documentation is required in the medical record?

A. 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., patient cooperation).
• The test findings (e.g., vascularization, opacity, defect, dellen, dendrites).
• A diagnosis (if possible).
• The impact on treatment and prognosis.
• The signature of the physician.

Q. What CPT code describes this test, and how is it paid?

A. CPT code 92285 (External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, stereo-photography) describes this service.

CPT code 92285 is defined as “bilateral” so reimbursement is for both eyes. At the time of this writing, the national Medicare allowable for 92285 is $41.97; of this amount, $30.63 is assigned to the technical component and $11.34 is the value of the professional component (i.e., 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.

Q. How often may this test be repeated?

A. 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.

Medicare utilization rates for claims paid in 2008 show that external photography was performed at 0.8% of all office visits by ophthalmologists. That is, for every 1,000 exams and consultations performed on Medicare beneficiaries, Medicare paid for this service eight times. The utilization rate for optometry is similar.

Q. What about bundles with other services?

A. According to Medicare's National Correct Coding Initiative (NCCI), code 92285 is bundled with the surgical codes for blepharoplasty procedures (CPT 15820-15824). Both gonioscopy (92020) and the level 1 established patient E/M code (CPT 99211) are bundled with external photos.

When these services are performed together, the claim for the external photos will be honored; the concurrent claims for gonioscopy and exam will be denied.

Q. What are Medicare's supervision rules?

A. Under the Medicare program standards, this test needs only 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. If Medicare doesn't cover external photography, may I charge the patient?

A. Sometimes. Be sure to 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 the patient's signature on an Advance Beneficiary Notice of Noncoverage prior to taking the photographs. 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

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.