Optometry Coding & Billing Alert

Question: Can I report a fundus photo and a Heidelberg retina tomograph (HRT) on the same day?

Texas Subscriber

Answer: Probably not. The Correct Coding Initiative (CCI) considers fundus photography (92250, Fundus photography with interpretation and report) mutually exclusive with HRT (92135, Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser] with interpretation and report, unilateral). Medicare carriers -- and other carriers that follow Medicare rules -- will not reimburse for both 92250 and 92135 if you report them together; you would receive payment for only 92135, the "Column 1" or comprehensive code. Many optometrists choose to circumvent this bundle by waiting to perform one of the tests on the patient's next visit.

Don't miss: You can unbundle the codes in some situations, such as when the optometrist performs each procedure on different eyes. On the other hand, CPT considers 92250 to be "bilateral" and carriers will pay the same for services performed on one or both eyes. Code 92135 is "unilateral," and insurers should pay services performed on each eye at 100 percent of the allowed amount for each eye. You will probably need to appeal a denied claim and should be prepared to provide documentation to support medical necessity and the need to perform both services, even if the diagnoses are different.

Example: An optometrist is monitoring a patient with different chronic conditions. He performs a scanning laser test (92135) to check on the progression of glaucoma and takes fundus photographs (92250) to track changes in diabetic retinopathy. Append modifier 59 (Distinct procedural service) to 92250, the "Column 2" or component procedure, to break the bundle.

In this case, you would need to very carefully assign the diagnosis to each of the tests, and documentation in the medical record must support the medical necessity for each test. In such a situation, you may want to have the patient sign an advance beneficiary notice (ABN) in case the carrier denies the claim.

Don't forget to append modifier GA (Waiver of liability statement on file) to 92135 when the patient has signed an ABN, accepting financial responsibility for a procedure or service in the event of a denial.