Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist performs external ocular photography for a Medicare patient with a malignancy on her left eyeball. Is this a covered service?

New York Subscriber

Answer: Based on the patient's diagnosis (190.0, Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid), the photography should be covered -- if your ophthalmologist is taking the photos in an effort to "track or treat" the malignancy.

Medicare will typically cover 92285 (External ocular photography with interpretation and report for documentation of medical progress) if the ophthalmologist is either: tracking the progression of the disease or checking the effectiveness of a particular course of treatment for the disease.

If your ophthalmologist orders the photography for either of these purposes, you should report 92285 to Medicare. But if you are unsure about your local carrier's policy, contact your local Medicare carrier before filing the claim.

If your ophthalmologist performed the photography to "track or treat" the disease, Medicare payers should deem 92285 medically necessary based on standards of care for your patient's diagnosis (190.0).

Other diagnoses that many Medicare carriers accept for 92285include these series:

• 190.x -- Malignant neoplasm of eye
• 364.5x -- Degenerations of iris and ciliary body
• 370.6x -- Corneal neurovascularization.

But not all Medicare carriers observe the same ICD-9 guidelines for 92285. So check with your local carrier if you have any questions. Cataract note: Medicare will not pay to photograph a cataract (366.xx) since it is not the standard of care to follow the progression of the cataract; instead the progression is tracked by measuring acuity.

If you have a case that you feel warrants a photo but you're not sure whether the diagnosis supports medical necessity for the insurer, you may want to consider obtaining a signed Advance Beneficiary Notice (ABN) from the patient before performing the service.