Ophthalmology and Optometry Coding Alert

Question: Is fundus photography covered by Medicare and other third-party payers, and what do we need to include to ensure reimbursement for 92250?

Vermont Subscriber

Answer: Medicare will reimburse you for fundus photography if the patient presents with a complaint that leads your ophthalmologist to perform this test as an adjunct to evaluation and management (E/M) of a covered indication. Check your payer’s local coverage determination (LCD) for diagnosis codes that support medical necessity. Images taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease are generally not covered.

The physician must document medical necessity and provide a formal report and interpretation. Photos should be labeled as to which eye, date taken, and date reviewed. Implications for patient diagnosis, management, and prognosis should be included.

Note: 92250 is defined as bilateral, so reimbursement is for both eyes. If only one eye is photographed, it is recommended to add modifier 52 (Reduced services) and a modifier to indicate which eye was photographed.