Ophthalmology and Optometry Coding Alert

Coding for fundus photography and fluorescein angiography (FA) tend to be confusing to coders because the physicians documentation usually doesnt separate them clearly as individual procedures.

The main reasons for denial of these two procedures are lack of supporting documentation and the absence of medical necessity, says Stephanie Habte, LPN, CPC, accounts receivable manager for Clarity Health Corp., a New York City-based company that bills for 14 ophthalmological practices.

Documentation for both FA and fundus photography should include the ophthalmologists initials and dated photographs, says Habte. This is in case of an audit. You have to show that the pictures were not taken later and put in the chart, she says. In addition, an interpretation must be documented for both the fundus photography and the FA. Most physicians already do this for the FA, but many neglect to do it for fundus photography because it seems redundant to them.

Coding for Fundus Photography

Fundus photography, code 92250 (fundus photography with interpretation and report), involves the use of a retinal camera to photograph the back of the eye. A 35-mm camera is used with a large ophthalmoscope. The ophthalmologist views the retina. A light is flashed, and a color photograph of the retina is produced. Both eyes are typically photographed. Code 92250 is bilateral, therefore, no additional allowance is paid if you perform the procedure on both eyes. The code should be submitted once, whether you perform the procedure on one or both eyes.

If you only do an interpretation and report for one eye, however, you should append the modifier -52 (reduced services), says Habte. You do both eyes with 92250 because it is a bilateral procedure. So if you do only one eye, its your responsibility to append the modifier -52.

Fundus photography usually is approved for retinal diagnostic codes, macular degeneration (362.50), and diabetes (250.0), says Habte.

Billing FA

FA, code 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report), is more complex than fundus photography because it involves injecting a dye into the patients vein. Then fundus photography is performed in a rapid series with a retinal camera. The purpose is to detect abnormalities in the retinal blood vessels. A black and white photograph is taken.

Unlike fundus photography, FA is a unilateral procedure in the Medicare program. If you bill 92235 alone, you will be paid for one eye onlyand that is correct if you only do the procedure (including interpretation and report) on one eye. If, however, it is medically necessary for you to perform the procedure on both eyes, you will need to use the modifier -50 to indicate that the procedure was performed bilaterally. Heres how to file with Medicare for FA when done on both eyes, the charge is $100 for 92235, and the payer is Medicare: Line 1: 92235, $100; Line 2: 92235-50, $100.

The dye injection, the intravenous line, and the developing of the images are all included in the code, says Habte.

A note on HMOs: If you perform 92235 on both eyes and the payer is an HMO, you probably will have a different rule for filing the claim, says Habte. They will most likely want you to file 92235-LT, $100 on line one, and 92235-RT, $100 on line two. As always, keep track of your payer requirements. If they do want you to use modifier -50 and one line, as some Blues and HMOs do, dont forget to double the units and double the amount: 92235-50, 2 units, $200.

Tip: Some private payers try to deny 92235 if performed by an ophthalmologist who is not a retinologist. There is no justification for such a denial: CPT codes can be used by any physician, and ophthalmic codes in particular can be used by any ophthalmologist, regardless of subspecialty.

Coding With an Office Visit

Medicare does allow for FA and fundus photography, as well as an office visit, on the same day, says Habte. Normally, you would use an E/M office visit code instead of an eye code, she says, because the procedures were done due to a problem. Some payers (not Medicare) try to say that if you are filing for 92235, you should not be paid for 92250 as well, since they are both photographs of the fundus. This arises from a lack of understanding by the managed care representative of the procedures, says Habte.

Yes, FA is usually accompanied by fundus photography, she says. But they dont realize that the FAs involve the dye injection and multiframe images. There is a lot more work involved with injecting the intravenous dye and looking at more pictures.