Optometry Coding & Billing Alert

Question: Our new software program instructs us to append modifier 50 to code 92250, but I wanted to double-check. Is it appropriate to use modifier 50?

North Dakota Subscriber

Answer: Medicare considers code 92250 (Fundus photography with interpretation and report) to be inherently bilateral. The relative value units (RVUs) for the procedure are already based on the procedure being done bilaterally. Therefore, you should definitely not report the code with modifier 50 (Bilateral procedure) appended. If you do, the carrier will most likely ignore it and just pay for one instance of 92250.

If the optometrist only photographed one eye, you may append modifier 52 (Reduced services), along with LT (Left side) or RT (Right side) as appropriate, to 92250 to show that he did not perform the full bilateral service.

Modifier 52 is an informational modifier and does not require you to reduce your fee.

Do this: Look in the "Bilat Surg" column in the Physician Fee Schedule to see if Medicare assumes a procedure is bilateral. For 92250, there is a "2" in that column, which means that the payment adjustment for a bilateral procedure does not apply. A "0" or a "3" in that column would also indicate no bilateral payment, while a "1" would tell you that you're free to append modifier 50.

Helpful resource: This info is also in Codify's fee schedule information at https://www.aapc.com/codify/medicare-fee-schedules.aspx.