Ophthalmology and Optometry Coding Alert

How you handle fundus photography claims today could affect the outcome of your next audit. Fundus photography, 92250 (Fundus photography with interpretation and report), a highly specialized form of medical imaging, is a common procedure that a technician performs. A fundus camera, which is attached to an ophthalmoscope, is aligned to view the back of the eye. Pictures are then taken of the optic nerve head, vitreous, macula, retina and its blood vessels to document any present pathology.

92250 is in CPT's special ophthalmological services section, which is a compilation of services that practices may report for Medicare in addition to the general ophthalmological services (92002-92014) or E/M services (99201-99499). Other payers, such as the "Blues," may try to bundle these services. But on the Medicare fee schedule, many of these codes have both a technical component and a professional component and, in CPT, have language that states, "interpretation and report by the physician is an integral part of special ophthalmological services," which sometimes goes unnoticed. The majority of codes in the special ophthalmological section are for diagnostic tests, i.e., 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2]), 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral), and 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report). Documenting Your Way to Clean Audits Though fundus photographs can be used to diagnose certain eye conditions, they are more often used to document a disease process or a diagnosis the physician has already observed. As a result, many ophthalmologists do not comply with the "interpretation and report" component of the code. "They also do not document the order for the photo consistently, thereby placing themselves at risk if they are ever audited," says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy based in Santa Barbara, Calif.

"Even though the payer rarely knows what the documentation looks like at the time they process [a claim] for payment, if the records are ever reviewed as part of an audit, and interpretations are not documented, then the practice will owe money back to the payer at a minimum," adds Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. The practice could even be fined for "billing for services not rendered," a recognized type of billing fraud by the Office of Inspector General (OIG) and [...]