Optometry Coding & Billing Alert

Question: Our optometrist performed fundus photography on both eyes for a Medicare patient. We reported 92250 with modifier 50 appended, and Medicare paid for only one code. Why didn't we get payment for the procedure on both eyes?

South Carolina Subscriber

Answer: You did get paid for both eyes. Medicare considers code 92250 (Fundus photography with interpretation and report) bilateral, meaning that modifier 50 (Bilateral procedure) is redundant on fundus photography claims. The calculated relative value units (RVUs) for 92250 include fundus photography for both eyes. If you report 92250-50, the carrier ignores it and just pays 92250 once.

Check this out: The Medicare Physician Fee Schedule contains column T ("Bilat Surg") for each code. In the fee schedule, 92250 has a "2" in column T, meaning the procedure is inherently bilateral.

You should also avoid billing bilaterally for any code with a column T entry of "0" or "3." Conversely, a column T entry of "1" frees you to report the code with modifier 50 appended.