Ophthalmology and Optometry Coding Alert

"Many ophthalmologists feel its necessary to perform 92250 (fundus photography with interpretation and report) and 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) together. As the descriptors indicate, both codes include an interpretation and report. But some ophthalmologists are asking, if these two procedures are done in connection, why they have to do an interpretation and report of 92250 if they have one for 92235 already in the chart. The short answer is: because CPT says so. Although payers dont always adhere to CPT requirements, in this case they will.

Include Separate Reports

Ophthalmologists should remember these two very important points when documenting reports for both 92250 and 92235:

1. Document medical necessity. If Medicare audits your charts and finds you are performing a fundus photo every time you perform a fluorescein angiogram (FA), they may think you have a standing order in place for the fundus photo, says Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology, based in Santa Barbara, Calif. A standing order is a request, policy or understanding that certain services are to be performed unless there is a specific order not to for the patient. (See box on page 43.) Without documentation of the specific physicians order for each test performed, you lack medical necessity for the service and will not be reimbursed by Medicare, says Duran. Medicare allows standing orders only in extended-care settings such as lengthy hospitalizations or nursing-home care. Even in those settings, Medicare requires that standing orders be checked with the provider(s) who set them on a regular basis to affirm that quality care is being delivered.

2. Document technical and professional components. In the Medicare program, services that have with interpretation and report in their description have relative value units (RVUs), or payment, allocated separately for the testing or technical component of the service, Duran explains. This usually is included in the global payment for the service (professional and technical) rendered by the same provider. It also can be recognized with a -TC modifier (technical component) if only the technical component is being provided. The physician interpretation, or professional component, can be recognized with the -26 modifier (professional component) if the provider is rendering only the interpretation and not providing or billing for the technical component.

When you report the global servicethe CPT code for the testing service without the -TC or -26 modifier attachedyou are reporting that you have performed both the technical and professional component of the service, Duran says. If you do not have documentation of both services in your medical record and bill the global service, you are billing for services not rendered. Repeated billing of services not rendered moves the billing error from the abuse classification into the fraud classification, explains Duran.

Include the Interpretation

The distinction between fundus photography and fluorescein angiography determines the interpretation of each. Fundus photography is one photograph of the back of the eye, using a special camera that takes a color photograph of the retina. It occasionally is called a red-freeze photograph or a color photograph. Fluorescein angiography involves injecting fluorescein dye into a vein in the arm and then taking a series of photographs, using a motorized camera, as the dye travels through the vasculature of the retina. Fluorescein angiography allows the ophthalmologist to detect leaks in the vasculature.

Fundus photography is used to document what the physician has seen upon his or her physical examination of the patient, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based coding, reimbursement and compliance consulting company. The physician orders fundus photography so that at a later time a subsequent photograph can be taken and used as a comparison to the initial photograph. This assists the physician in judging any progression in the disease process that may have taken place between examinations.

Fluorescein angiography, on the other hand, is used to document the status or progression of the disease process and as a diagnostic tool to reveal the functioning of the vasculature of the eye (i.e., leakage that cannot be seen on direct examination), says Roberts.

The problem with performing and billing for these two procedures at the same time is that most practices do not document the fundus photography service properly. As stated above, a physician order is required for all testing services, yet upon review when many physicians want the ocular lab to perform both testing services, they only indicate in the record FA today, says Roberts. The correct way to document the order would be to indicate both testing services and whether the physician wants the testing services performed on the right eye, the left eye or both.

In addition to not documenting the order for the fundus photo, many physicians also forget to document their interpretation of the photo, Roberts explains. Since the photo serves to document what the physician has seen upon examination, many offices do not route the photo back to the physician for review. But it is absolutely necessary to return the photo to the physician along with the FA for a written interpretation.

So how can there be a different interpretation of the photo if it documents what the physician saw upon examination? There usually isnt, says Roberts. The interpretation is typically exactly what the physician documented upon examination. This is why physicians dont feel it is necessary to interpret the photowhy document the same findings twice? Well, if you dont want to document it twice, you dont have to bill for the interpretation, says Roberts. If you do not write an interpretation of the photo you could bill only for the testing service, 92250-TCand receive about 25 percent of the total payment for the global service.

So how extensive does the documentation of the physicians interpretation have to be to bill for the entire service? The interpretation can be a notation on the picture or slide, an entry on the progress note or a simple form, Roberts explains. If the photo is of a choroidal nevus (224.6) and the physician is able to estimate the size, write down that information and initial it. You also can state, Photo consistent with examination findings of _____ and list the date just be sure the fundus was described in sufficient detail in the medical record.

There is no problem with a physician billing for both 92250 and 92235, says Heather Freeland, a consultant with Rose and Associates, a compliance and reimbursement consulting firm based in Duncanville, Texas, that specializes in ophthalmology providing there is an order and written interpretation for both.

If you code for the FA, you must provide documentation of your interpretation and report. Likewise, if you code for the fundus photography, you must provide documentation of the interpretation and report. You must also document the medical reason for both.

Interestingly, notes Freeland, Medicare has not bundled 92250 and 92235 but has bundled 92250 with 92240 (indocyanine-green angiography [includes multiframe imaging] with interpretation and report). The 92240 procedure involves injecting dye into the arm and taking a sequence of photos with a motorized camera. It sounds a lot like fluorescein angiography, except that the choroid, not the retina, is photographed, and the photographs are shot every 10 seconds instead of every 30 minutes. Unlike the fundus photography-fluorescein angiography combination, 92240 and 92235 are almost never done together, says Freeland.

Getting Paid Does Not Mean Avoiding Fraud

You may be getting paid without putting reports for both procedures in the file. You also may be getting paid for both procedures when you have medical necessity to do only one. But Medicare might come back and scrutinize your charts in a postpayment audit, says Ramona Cosme, president of Edison, N.J.-based Ramco Medical Billing, a coding and reimbursement consulting firm specializing in ophthalmology. Then, you may well owe money.

In an audit, the carrier cannot only recoup payments made in error, but also can levy penalties. Two different errors can be found if you get audited:

1) professional component fees repeatedly paid in error because the interpretation wasnt documented although there was a documented order for the fundus photography;

2) neither an order nor an interpretation is documented for the fundus photography, and professional and technical component fees are paid in error.

In the first scenario, the professional component would be subject to recoupment and penalties. In the second scenario, both components would be subject to recoupment and penalties.

Freeland puts it this way: Medicare payment to the physician can be considered a temporary measure. As she says, Medicare can come back anytime and ask for the money back. The worst thing you could say, in trying to explain why its important to do both fundus photography and fluorescein angiography, is, I always do both together. That, to Medicare, signals that you do not have medical necessity. So dont get too much reassurance from the fact that you may be getting paid for both you may be getting lured into a false sense of security.

Examples of Standing Orders Here are two examples of a standing order" courtesy of Raequell Duran president of Practice Solutions a coding compliance and reimbursement consulting firm specializing in ophthalmology based in Santa Barbara " Calif.: 1) An ophthalmologist who is a subspecialist in glaucoma is referred a patient by another physician. The receptionist or appointment scheduler" who makes the appointment for the patient knows that whenever her physician sees a new patient " he or she likes to have a visual field performed (baseline). Even though the physician hasnt seen the patient" the receptionist schedules the patient to come in for a visual field test which is done first then an office visit with the physician. Because the visual field was scheduled and performed before the physician saw the patient there was no physician order for the test for that patient " which is required. 2) The physician sees a patient and determines that a fluorescein angiogram (FA)" code 92235 is needed. He or she writes FA today or FA OU/OD/OD in the record. This is the order for the FA. The patient goes to the ocular lab and the FA is performed along with a fundus photo (92250). There is no order for the fundus photo for this patient but the lab has the impression or has been told by the physician to perform a fundus photo on every patient that is there for an FA.

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