Ophthalmology and Optometry Coding Alert

Hint: 92250 plus these diagnostic tests should add up to $75 per patient

 In 2003, Medicare allowed over 1.5 million charges for fundus photography, reimbursing eye practices over $100 million - and to get your fair share, you need to be sure you're following these diagnostic-procedure coding guidelines.
 
Ophthalmologists often take fundus photographs in tandem with other diagnostic procedures, to document a disease process or follow the progress of a disease. But trying to code for all the services performed along with fundus photography can be tricky.

Find Separate Reasons for Fundus and FA

Many ophthalmologists perform 92250 (Fundus photography with interpretation and report) and 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) together as a standard of care. And there's no problem coding for both - as long as you have an order and written interpretation for both, says Donna Marks, CPC, CCS-P, OCS, ophthalmology coder for the Lahey Clinic in Peabody, Mass. Note that both descriptors specify that the codes include the interpretation and report. The ophthalmologist needs to document them separately for each procedure, Marks says.
 
Key: The two tests are done for different reasons, experts say. Fundus photography (also known as a "red freeze" or "color" photograph) is one photograph of the back of the eye, using a special camera that takes a color photograph of the retina. The ophthalmologist orders fundus photography to document what he finds upon examination and so he can take another photograph later and compare it to the first. This helps him judge any progression in the disease process that may have taken place between examinations.
 
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.
 
Medicare carriers should have no objection to coding both tests - in fact, many won't have it any other way. "Medicare will cover fundus photography if accompanied by fluorescein dye angiography when used to evaluate abnormalities or degeneration of the macula, the peripheral retina or the posterior pole," says a local coverage determination (LCD) from First Coast Service Options, the Part B carrier for Florida and Connecticut. Many carriers, such as Palmetto GBA in Ohio, South Carolina and West Virginia, will only cover stand-alone fundus photography done by the surgeon of record for "therapeutic assessment of recently performed retinal laser surgery."
 
Watch out: Not all angiographies are created equal, says Jacqueline Arriola, CPC, coder for Yuma Eye Associates in Arizona. NCCI bundles 92250 into 92240 (Indocyanine-green angiography [includes multiframe imaging] with interpretation and report), which means that Medicare considers fundus photography to be an intrinsic part of the angiography procedure. Do not report 92250 and 92240 separately.

Beware OCT Bundles

The rules are stricter regarding fundus photography performed with scanning laser imaging such as OCT, HRT or GDx. The National Correct Coding Initiative (NCCI) bundles 92250 and 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) as a mutually exclusive pair, Marks says. The bundle is marked with a modifier indicator of "1," meaning you may be able to report them together by appending a modifier to 92135, as long as your documentation supports the necessity of both.
 
Many carriers, including Palmetto, Empire (the Part B carrier for New Jersey and part of New York), HealthNow (upstate New York), CIGNA (Idaho, North Carolina and Tennessee) and Blue Cross and Blue Shield of Kansas (Kansas, Nebraska and northwest Missouri), have LCDs for 92135 explicitly saying that 92250 "would generally not be necessary with SCODI. When needed the same day, documentation must support the procedures."
 
Example: An ophthalmologist is following a patient with different chronic conditions. "He may perform the SCODI to check on the progression of glaucoma while the fundus photography is performed to track changes in a patient with diabetic retinopathy," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "In this case, the diagnosis would need to be very carefully assigned to each of the tests, and documentation in the medical record must support the medical necessity for each test." In such a situation, you may want to have the patient sign an advance beneficiary notice (ABN) in case the carrier denies the claim, Mac says.

Avoid EO Redundancies

Carriers have different rules regarding extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) when performed with fundus photography.
 
Problem: While no longer bundled by NCCI, these two codes represent potentially redundant procedures. Some carriers bundle the payment for fundus photography into the payment for the extended ophthalmoscopy. For example, HealthNow may deny the EO "as not medically necessary if it is anticipated that no new additional information, above that available from the photography, will be obtained." Tufts, an HMO in Massachusetts, will always deny 92225 or 92226 (... subsequent) as included in 92250. Check your carrier for an LMRP or LCD; if the carrier doesn't state otherwise, you should be able to bill both separately without appending modifier -59 (Distinct procedural service).
 
Tip: Many ophthalmologists only report 92225 and 92250 together when they can document a change in the optic disk or retina or a change in the visual fields if all is normal. Many LCDs support this strategy. For example, Regence Blue Cross and Blue Shield of Utah's policy states, "Fundus photographs are not medically necessary simply to document the existence of a condition. Photographs are medically necessary to establish a baseline to judge later if a disease is progressive."
 
Photographing a patient to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy, then comparing that photograph to the patient's clinical appearance four months later, would be acceptable, Regence says.

Separate Fundus Photos, Gonioscopy, VF From E/M

Ophthalmologists routinely perform fundus photography as part of a typical diagnostic evaluation for glaucoma. These examinations also usually include measuring visual acuity, checking the intraocular pressure, gonioscopy, pupil dilation and visual field examination.
 
Of these typical components of a glaucoma exam, you can code fundus photography, gonioscopy (92020, Gonioscopy [separate procedure]) and visual field examinations (92081-92083) separately from the E/M or eye examination code, Arriola says. Check with your carrier, however; these services can sometimes have specific frequency limitations.