Ophthalmology and Optometry Coding Alert

Question: My Medicaid carrier just requested repayment for all claims for fundus photography performed on the same day as nerve head analysis with an OCT. Should I appeal this?

Alabama Subscriber

Answer: You certainly can appeal, but your chances arent good. The National Correct Coding Initiative places 92250 (Fundus photography with interpretation and report) in a mutually exclusive bundle with 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser], with interpretation and report, unilateral), a.k.a. optical coherence tomography (OCT). Many carriers see 92250 as a procedure that would not be necessary along with 92135.

The rule has caused many ophthalmologists to try to avoid performing 92135 and 92250 on the same day unless medically necessary due to health or transportation problems with the patient. For example, an ophthalmologist might perform OCT at a six-month progress visit and fundus photography at an annual exam.

If you do need to perform both tests at one session, carefully document the medical necessity and report both codes, appending modifier 59 (Distinct procedural  service) to 92135.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M.Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley,and Associates in Clearwater, Fla.