Ophthalmology and Optometry Coding Alert

Getting paid for doing fundus photography and an examination on the same date can be difficult, if not impossible. As Brent E. Walker, MD, of Erie, PA writes, When I examine a glaucoma patient and do photos of the optic disc, I usually bill using codes 92012 for the eye exam and 92250 for the fundus photos. Why, he asks, are the fundus photos denied if he does them the same day? And how can he get them paid instead of denied?

Walker is using the right codes; the problem is that he is using them together. Medicare doesnt want to pay for fundus photos unless they are done on a different day from the eye exam. We talked to three coding experts about possible solutions to this dilemma.

1. Try an E/M code. Betty Torres, CPC, manager for patient accounts in the department of ophthalmology at the University of Texas Medical Branch-Galveston, where there are eight faculty ophthalmologists and twelve residents, uses an E/M code instead of an eye exam code. She uses modifier -25 on the E/M code, and gets paid for both the office visit and the fundus photos. (An added benefit of using the E/M code is that the Medicare carrier reimburses E/M codes much better than the eye exam codes.)

2. Medical necessity. They will pay for the fundus photos, but it needs to be medically necessary, says Torres. And you need to document the medical necessity. You need to check with your carrier for the guidelines on how often fundus photography is considered necessary for glaucoma patients, she adds. How do you prove medical necessity? If there is a separate diagnosis, states Torres. For example, if the patient has conjunctivitis, and fundus photography is done for glaucoma, then you would use a modifier -25 on the office visit. This kind of problem crops up often in a university setting, she notes. The residents dont have coding expertise, and may want to do several services on the same day, which could be done on different days, she explains. (Tip: Check with your Medicare carrier to find out what specific list of diagnoses validate fundus photography.)

3. Scheduling. Some practices bring patients back for the fundus photography. This is a scheduling solution to the problem, and one which works for Candace Simerson, COA, administrator of Eye Physicians and Surgeons, a 10-provider (eight ophthalmologists, two optometrists) group in Edina, MN. After the eye exam, the physician tells the patient to come in for fundus photography, says Simerson, who is president of the American Society of Ophthalmic Administrators. This works better for many reasons, she notes. You can set up a block of time, and have the technician do nothing but fundus photography, adds Simerson, whose practice has 10 locations.

Would two visits in one week -- one for an eye exam, and one for fundus photography -- make a payer suspicious? If it becomes too flagrant, you could have problems, Torres cautions. If you routinely see a patient one day and call them back the next for fundus photography, that would send up a red flag, she says.

Eric Sandhusen, CPC, principal consultant with Review Associates, a coding analysis and compliance firm based in Flagstaff, AZ, says there are situations in which you could defend this practice. For example, say you have a multiple-site practice like Simersons, and your technicians are in certain offices on certain days. It would clearly make sense to block off time for fundus photography, and to bring patients in at that time. If the technician is only in on a specific day, that would pass muster, says Sandhusen.