Ophthalmology and Optometry Coding Alert

Question: Im confused about billing for fundus photography. Should we bill for both eyes separately? Also, can we bill for fundus photography to rule out or confirm certain conditions?

New York Subscriber
 
Answer: According to the local medical review policies (LMRPs) for the Upstate Medicare Division on fundus photography (92250, fundus photography with interpretation and report), the fee schedule allowance is based on performing the procedure bilaterally. Therefore, neither modifier -50 (bilateral procedure) nor the -LT (left side [used to identify procedures performed on the left side of the body]) or -RT (right side [used to identify procedures performed on the right side of the body]) modifier is appropriate. You will be paid for both eyes whether you do only one eye or both. If the procedure is performed on one eye, append modifier -52 (reduced services) to indicate that a bilateral service was not performed.  
 
Do not bill 92250 for rule-out purposes; you must use an accepted condition (the list of accepted diagnosis codes is long). Do not bill 92250 for screening purposes; a screening diagnosis code (V82.9, unspecified condition) will definitely lead to a denial. For example, the LMRP says fundus photography is not necessary to determine the presence of dry, age-related maculopathy; however, it may be necessary to tell how far retinal edema has progressed in nonproliferative diabetic retinopathy. Use the information on the progress of the edema to determine whether to perform focal laser photocoagulation and not merely to document the progression of disease. 
 
This information reflects the LMRP for the Upstate New York Medicare Division and is used as an example only. You should become familiar with the LMRPs for your state for billing fundus photography.