Optometry Coding & Billing Alert

Question: If you perform 92250 (fundus photography) on a patient with diabetes and later find out that there is no retinopathy procedure that you can bill with this code, will any insurance provider pay for it? It seems to me that a diabetes diagnosis would make this procedure medically necessary as a baseline even if there is no retinopathy.

Alabama Subscriber

Answer: You cannot bill for photos even for a diabetic patient if the patient has not been diagnosed with retinopathy. Only when there is retinopathy can you bill photos. A mere photograph of the retina cannot be used to establish a baseline for diagnosis and billing.

CPT defines code 92250 as "fundus photography with interpretation and report." In this particular service, there are several integral parts: (1) the retinal image taken by the camera or other imaging tool, (2) the chart documentation, and (3) the professional interpretation and report by the physician.

The technical aspects of special ophthalmological services which may or may not be performed by the doctor are "part of the service but should not be mistaken to constitute the service itself," according to CPT. Thus, a physician cannot charge for 92250 on the sole basis that a technician captured an image of a patient's retina and has placed it on the record.

The case is similar to extended ophthalmoscopy (92226). If there is no diagnostic basis to support the finding, you cannot charge for it.

Bottom line: The insurance provider will only pay if there is disease present in the eye as in retinopathy. Otherwise, it is considered a screener/preventative and not covered. In other words, you can't get paid to take a picture of a normal retina, even if the patient has a disease.