Optometry Coding & Billing Alert

Question: Can I report a fundus photo and a Heidelberg retina tomograph (HRT) on the same day if I use modifier 59 on the fundus photo code?

Texas Subscriber

Answer: In most cases, no. The Correct Coding Initiative (CCI) considers fundus photography (92250, Fundus photography with interpretation and report) to be 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 codes if you report them together. You would only receive payment for 92135, the "Column 1" or comprehensive code.

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 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 and accepted financial responsibility for a procedure or service in the event of a denial.