Optometry Coding & Billing Alert

Question: My Medicaid carrier just requested repayment for all claims for fundus photography performed on the same day as nerve head analysis with an OCT. Should I appeal this?

Answer: You certainly can appeal, but your chances aren't good. The Correct Coding Initiative (CCI) places 92250 (Fundus photography with interpretation and report) in a "mutually exclusive" bundle with 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, [e.g., scanning laser], with interpretation and report, unilateral), also known as optical coherence tomography (OCT). Many carriers see 92250 as a procedure that would not be necessary along with 92135.

The bundle may be a result of Medicare's concern about providers overusing 92135. The rule has caused many optometrists to try to avoid performing 92135 and 92250 on the same day unless medically necessary, due to health or transportation problems with the patient. For example, an ophthalmologist might perform OCT at a six-month progress visit and fundus photographs at an annual exam.

If you do need to perform both tests at one session, carefully document the medical necessity and report both codes, appending modifier 59 (Distinct procedural service) to 92135.

Beware: Many carriers may also be leery of paying for 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial), 92226 (... subsequent), or 76512 (Ophthalmic ultrasound, diagnostic; B-scan [with or without superimposed non-quantitative A-scan]) on the same day as an OCT. Check with your carrier for restrictions.