Ophthalmology and Optometry Coding Alert

The answers to these FAQs about 92250 can earn you $82 per procedure

Fundus photography -- CPT code 92250 (Fundus photography with interpretation and report) -- is one of the most frequently performed procedures in ophthalmology offices across the country. As a result many coders have questions about how best to report this diagnostic test in which a fundus camera attached to an ophthalmoscope takes pictures of the optic nerve head vitreous macula retina and its blood vessels to document any present pathology. Our experts'advice can steer you toward full reimbursement -- and away from denials.

A: The CPT codes descriptor doesn't explicitly say whether 92250 is inherently unilateral or bilateral. According to Medicare's Physician Fee Schedule however it's a bilateral procedure. CMS values 92250 at 2.19 RVUs which multiplied by the current conversion factor of 37.3374 yields an allowance of $81.76. Column T of the fee schedule gives fundus photography a bilateral surgery indicator of 2 -- meaning that the RVUs are already based on the procedure being performed as a bilateral procedure.

But what if you only photograph one eye? "What we do is add modifier -52 (Reduced services) to 92250 " says Amanda Kunze CPC reimbursement specialist at the Eye and Ear Clinic of Wenatchee in Wenatchee Wash "and then the -RT or -LT modifier depending on which eye we did photograph."

A: Report 92250-TC (Technical component) to show that you only performed the technical component not the professional component (the interpretation) of the procedure. "In some cases our office will do [a procedure] for a physician who does not have the particular equipment that we have " says Edith M. Johnson CPC ophthalmology coding specialist at the Springer Clinic in Tulsa Okla. "And so we'll code for the -TC and then the other surgeon bills for the -26 (Professional component)." The technical component of 92250 is valued at 1.54 RVUs ($57.50) while the professional component is valued at 0.65 RVUs ($24.26).

A: No Johnson says. The "Level of Physician Supervision" for 92250 (found in Column Z of the Physician Fee Schedule Database) is 1 which means according to Medicare that it "must be performed under the general supervision of a physician." The physician maintains overall direction and control of the procedure -- but his presence is not required. In other words the physician must order the diagnostic test but need not be in the office when it's performed.

A: Probably not Kunze says. In 2000 the National Correct Coding Initiative made 92135 (Scanning computerized ophthalmic diagnostic imaging with interpretation and report unilateral) mutually exclusive with 92250. You may be able to report the two codes together with modifier -59 (Distinct procedural service) if you have documentation proving both procedures were medically necessary. If you report the two codes together without modifiers "you would get denied " Kunze says. You would most likely only see reimbursement for the fundus photography which carries more RVUs.

A: 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. Similarly 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician) -- sometimes called the "Nurse Visit" code -- is bundled into 92250 and the rest of the ophthalmological diagnostic procedure codes.

A: Ophthalmologists often must perform 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) together with 92250. But they sometimes only think it's necessary to document the interpretation and report for one of the tests thinking that having both in the chart would be redundant.

Red flag: That's a mistake Kunze says and it could be a costly one. "We do [interpretation and report] for both " she says "because both codes require it." The CPT code definitions clearly state that "interpretation and report" are part of both procedures.

"Our doctors are pretty good now about doing reports for all of the testing " Kunze says. "They'll do the fundus photography even if it's the second or third time and state what they see whether it's changed or if there's a difference. And then if the FA is done they'll dictate a whole separate report on their findings why they did it to begin with and what the final diagnosis code was."