Ophthalmology and Optometry Coding Alert

Use Medicare’s LCDs as your viewfinder for fundus photos and EO payment.

When you’re putting something together — think IKEA flat packs — you’ll have a lot easier time doing the job and a lot better result if you actually follow the guidelines.

The same general principal holds true for your fundus photography and extended ophthalmoscopy claims: If you follow Medicare’s local coverage determination (LCD) guidelines, you’ll have a lot easier time putting together a claim that’ll work and get your practice paid.

“You’d be surprised by how many providers don’t know about the LCDs and, therefore, aren’t following the guidelines, which leads to increased errors we see,” a presenter from National Government Services’ (NGS) told attendees during the April 2019 Medicare University webinar, “Ophthalmology Services: Posterior Segment Imaging.”.

The key? Submitting medically-necessary diagnoses and including the right photographic images to support your physician’s work for your Medicare beneficiaries. Follow this instruction from NGS to construct compliant, payable imaging claims.

First Things First: Who Does the Work?

NGS is clear that only ophthalmologists — (MDs) and doctors of osteopathic medicine (DOs) — who’ve completed an ophthalmology residency that specializes in eye and vision care and fully-qualified optometrists can provide interpretation and analysis. That means other physicians, such as primary care doctors who haven’t completed ophthalmology residencies, aren’t authorized to provide these services, said an NGS representative in the presentation.

Medicare’s policy is that a doctor of optometry “is considered a physician with respect to all services the optometrist is authorized to perform under state law or regulation,” added the rep.

FP & MDM: Focus on Reasons for the Test

Your physician uses fundus photography (FP), during which an image is taken of the posterior segment, to document abnormalities of the retina and disease processes affecting the eye and to follow the progression of the disease. To report these FP services, you’ll use CPT^® code 92250 (Fundus photography with interpretation and report).

If the FP study is performed as a screening service, it is not covered by Medicare, the NGS rep clarified during the webinar.

Also, FP isn’t considered medically necessary and is, therefore, not covered, says NGS, if:

• it’s used more than twice a year without appropriate documentation to explain why it was performed more than twice; or
• the image shows a normal retina.

The big takeaway, from a reimbursement standpoint, is that your physician uses FP to image an abnormal retina or track eye disease process — and that your documentation confirms this. It’s all about proving medical necessity.

What you have to show, according to NGS’ LCD guidelines (L33567), is that the test was used in the physician’s medical decision-making for patients with conditions such as:

• Macular degeneration
• Retinal neoplasms
• Choroid disturbances
• Diabetic retinopathy
• Glaucoma
• Multiple sclerosis.

Resource: To see more approved FP diagnoses, visit the NGS site at www.ngsmedicare.com. Sign in as a guest if you don’t have an account, type in “L33575” in the LCD box, and then click on the link “LCD for Ophthalmology: Posterior Segment Imaging (Extended ophthalmoscopy and fundus photography).”

Support FP with This Documentation

Remember that for fundus photography claims to be ironclad, you need to show clearly that your physicians are using it to track a disease process or to plan treatment for a disease process.

Again, you have to show medical necessity. To do that, you need the fundus photographs and an interpretation and report of the test, says NGS. And you’ll need to include these items, as well:

Relevant medical history;
Physical examination;
Results of diagnostic tests/procedures; and
Which pupil was dilated and what drug was used.

Best handwriting: It’s all got to be legible, says NGS, and maintained in the patient’s record.

Review How You’re Handling Extended Ophthalmoscopy

When your physician uses extended ophthalmoscopy (EO) to examine and generate a drawing of the retina, you’ll report 92225 (Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial) for the first exam and, if needed, 92226 (… subsequent) for another exam on the same patient.

Quick review: An EO will include a “true drawing” of the retina, says NGS, with interpretation and report from your physician. The procedure’s performed using an indirect lens or contact lens biomicroscopy and may require scleral depression to examine the retina’s outside edges. The patient’s pupils are dilated.

Critical: Like FP, an EO must be used in medical decision-making to merit Medicare pay and must be deemed medically necessary.

Heed These Key EO Limitations

Knowing what will trigger a denial is always a good idea. This holds true for extended ophthalmoscopy claims, as follows:

Like FP, Medicare won’t pay for extended ophthalmoscopy when it’s used as a screening service.

Also, most of the conditions that establish the medical necessity of EO usually won’t require more than two exams, per eye, per year, per beneficiary, said the NGS rep in seminar. (There are circumstances, however, when more than two exams per year are acceptable. See indications for those in “How Often Can You Bill EO?”)

Dx Lineup — What Establishes EO Medical Necessity?

Age-related macular degeneration is one of the top reasons Medicare beneficiaries would need EO, says NGS, but there are many conditions that would support medical necessity for the exam and the resulting drawing, interpretation and report, including:

Retinal detachment
Diabetic retinopathy
Disorders of the vitreous body
Posterior scleritis
Glaucoma
Retinal edema

Resource: To see additional approved diagnoses, go to the NGS site and follow the path to L33575, the LCD for posterior segment imaging.

If your doctor does repeat the exam and fails to document changes in the patient’s condition or signs and symptoms of new abnormalities, your claim for the EO service may be denied as medically unnecessary.

There’s more: If you omit the interpretation and report details, you’ll get a denial. Without analysis details, you aren't providing evidence of medical necessity, NGS explains.

And the same holds true of the retinal drawing — if it’s missing or fails to meet the required standards (described in more detail in this article), the EO service will not be separately payable.

Lastly: If your physician performs EO post-surgery to “document successful outcomes,” Medicare is not likely to view this as medically necessary. The reason? The EO is included in the post-surgery aftercare and isn’t separately billable, says NGS.

If, however, your physician needs to use EO to image and analyze a suspected condition that’s unrelated to the ophthalmologic surgery the patient just had, that service may be separately reportable during the surgery global period.

Check Your Record for These EO Items

Think like a trial lawyer: What you need to prove to Medicare is that the extended ophthalmoscopy service you’re billing supports medical necessity beyond a reasonable doubt — and your patients’ medical records are your best evidence. Remember the old chestnut, “If it’s not documented, it didn’t happen.”

Your records, says NGS, must contain the following to support EO:

• Relevant medical history;
• Physical examination details;
• Results of diagnostic tests/procedures for each eye. If your physician needs to perform other tests, such as an FP or an optical ultrasound, make sure she documents the reason there’s a need for multiple imaging or the EO will be denied as not necessary, said an NGS rep in the webinar; and
• Retinal drawings that meet Medicare’s specifications (see “Becoming Rembrandt” below).

How Often Can You Bill EO?

Medicare lets you report extended ophthalmoscopy multiple times per eye, per year for certain specific conditions, as outlined by NGS presenters in the webinar:

Becoming Rembrandt: Perfect Your Retinal Drawing

Call forth your inner artist and address these specifications for your EO retinal sketch, as outlined by NGS in Appendix A of their LCD for posterior segment imaging. Here’s a partial list of what’s required, as indicated in L33567:

Must be a separate detailed sketch, minimal size of 3-4 inches.
All items noted must be identified and labeled.
Drawings in four– to six standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.
Optic nerve abnormalities should be separately drawn.
An extensive scaled drawing must accurately represent normal, abnormal, and common findings such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears, or tumors.
Documentation in the patient’s medical record for a diagnosis of glaucoma (ICD-10-CM codes H40.001-H40.152 Glaucoma) must include all of the following:
          A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment;
​          Documentation of cupping, disc rim, pallor, and slope;
​          Documentation of any surrounding pathology around the optic nerve;
​          Documentation specific to the method of examination (e.g., lens, scleral depression; instrument used) should be maintained in the medical record.

It’s worth the effort: “Most of the records that we reviewed did not have substantial drawings and this is required,” stressed the NGS rep during the presentation. “Pay close attention to the quality of the retina drawing, as well as the severity and progression of the disease,” she added.

Resource: For further review of the requirements in Appendix A, go to https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/33567_6/APPENDIXA.pdf.

1. Up to 12 times: Patients actively being treated with intravitreal injections of medication for exudative age-related macular degeneration (ICD-10-CM code range H35.32xx)

2. Up to six times: For patients with such conditions as tuberculous chorioretinitis (ICD-10-CM A18.53; A18.54) and diabetes with ophthalmic complications, diseases of the eye and adnexa (E08.311-E08.359)

3. Up to four times: Patients with neoplasms of the eye and adnexa (ICD-10-CM codes C69.20-C69.42; C79.89-C79.9; D31.20-D31.32)

Generally, though: Most other conditions usually require no more than two extended ophthalmoscopic examinations per eye, per year, says NGS.

Caveat: As with FP, when extended ophthalmoscopy is provided during the global post-operative period of ophthalmic surgery, it’s included in the aftercare of the patient and is not separately billable, says NGS.

Further resource: To review a fact sheet on Medicare Vision Services, see www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/VisionServices_FactSheet_ICN907165.pdf.