Ophthalmology and Optometry Coding Alert

Question: We submitted a claim for 99204 and 92250 to Medicare. The diagnosis code for both services was 250.50. The denial says, "missing/incomplete/invalid diagnosis or condition." Why is Medicare continuing to deny this claim?

Ohio Subscriber

Answer: You may need an additional ICD-9 code to identify the specific ophthalmic problem the patient presents with.Code 250.50 (Diabetes with ophthalmic manifestations; type II or unspecified type, not stated as uncontrolled) is the correct code for type II diabetes with ophthalmic manifestations, but ICD-9 rules require you to use a second diagnosis code to say what, exactly, the ophthalmic manifestations are. Fundus photography must have a specific diagnosis of what, exactly, is being photographed.

Link the E/M code (for example, 99204, Office or other outpatient visit for the evaluation and management of a new patient ...) and 92250 (Fundus photography with interpretation and report) to the ophthalmic manifestation -- such as macular edema (362.07), glaucoma (365.44), or retinopathy (362.01-362.06) -- as a secondary diagnosis. Be sure to check with your carrier, though. It is possible that it may want just the manifestation code, not the diabetes code. Also, look at the approved code list included in your carrier's local coverage determination for ICD-9 codes that prove medical necessity for the fundus photography.