Ophthalmology and Optometry Coding Alert

To get fundus photography claims paid via Medicare, you’ve got to heed these requirements, advised a National Government Services presenter during the April webinar on Medicare’s posterior imaging LCD.

1. You must include a written interpretation. If an interpretation isn’t included in the medical record with the photograph, then the professional and technical components of the FP will be considered not medically necessary, said the NGS rep in the webinar. As long as that interpretation is in the same medical record with the photograph, you’re covered, added the rep.

2. Expect a reduction in your fee if you perform FP unilaterally (i.e. on just one eye). Code 92250 (Fundus photography with interpretation and report) is an inherently bilateral service as indicated on the Medicare Fee Schedule, says NGS, so services performed unilaterally will be subject to a fee reduction.

If your provider only photographed one eye, append modifier 52 (Reduced services) so the insurance company is aware of the unilateral nature of the service, advises Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology of Canandaigua, NY.

3. You can’t substitute FP for an annual dilated exam.

4. Remote imaging for retinal disease detection is non-covered. This service, which you’ll report with code 92227 (Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral) is considered a screening test, NGS says, and will be denied as non-covered.

Bear in mind: Though you can’t bill 92227 or 92228 (Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral) for remote imaging with an E/M or eye code, you may bill optic nerve scan code 92133, retina scan code 92134, and FP code 92250 with either an E/M code or an eye code. Also 92133 or 92134 cannot be billed at the same session as 92250 (unless there is a very specific reason to unbundle them), confirms Vanderwall.

5. You can’t use FP as a screening test to facilitate a referral to a specialist. If a provider other than an ophthalmologist or optometrist uses fundus photography as a screening test to facilitate referrals to a specialist, that’s contrary to requirements for testing as indicated in the federal code of regulations, the NGS rep said in the webinar, and is therefore not covered.

6. Don’t expect payment for a FP that’s performed prior to a physician specialist’s face-to-face encounter with the patient. This isn’t reimbursable, NGS confirms.