Ophthalmology and Optometry Coding Alert

Question: An ophthalmologist in our practice would like to offer baseline photos, taken with his fundus camera, for patients who are interested. Can we charge a different fee compared to photos taken to monitor disease that include an interpretive report?

Nevada Subscriber

Answer: Start with medical necessity. Are the photos considered to be medically necessary for the care and treatment of the patients condition? If the answer is "no," the first step is to obtain an Advance Beneficiary Notice of Non-Coverage (ABN) and indicate that the photos are an option but not clinically necessary for the patient's clinical care. Include the cost of obtaining the photos. If the patient elects to have the photos and accepts financial responsibility, you can proceed with obtaining the photos. You should bill for just the technical component of the fundus photos. Report 92250-TC-GA (Fundus photography with interpretation and report; technical component). Append modifier TC to show that you just performed the technical portion of the procedure, not the professional component (modifier 26, Professional component) of interpreting and reporting the results.

You may also want to give a form to new patients explaining the advantages of retinal photography and that Medicare will not cover it. The ABN is then used to show the physician recommendation for the photos and the patient has the option to check "yes" or "no" on the form to indicate that he does or does not accept the procedure and is or is not willing to be responsible for the charge for the photos.

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.