Optometry Coding & Billing Alert

Question: We are having trouble collecting for both 92250 and 92133 when the optometrist reports both fundus photography and optic nerve imaging. Can you advise?

Answer: Often, an optometrist will perform fundus photography with other diagnostic procedures to document a disease process or follow its progress. Any carrier that follows Correct Coding Initiative (CCI) edits will consider 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) and 92134 (…retina) to be mutually exclusive with 92250. It would not be appropriate typically to bill for both in the same visit.

CCI marks this bundle with a modifier indicator of “1,” meaning you may be able to report them together by appending a modifier to 92133 or 92134. But payers will want you to have documentation supporting your decision to code both procedures.

Example: The optometrist is monitoring a patient who has glaucoma and diabetic retinopathy. He checks the glaucoma’s progression with a scanning laser test (92134) and takes fundus photographs (92250) to track changes in diabetic retinopathy. Be sure you link a glaucoma diagnosis, such as 365.11 (Primary open angle glaucoma), to 92134, and a diabetic retinopathy code, such as 362.05 (Moderate nonproliferative diabetic retinopathy), to 92250.

Your documentation 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.