Optometry Coding & Billing Alert

Getting fully reimbursed for 92250 is a snap--if you know the bundling and bilateral rules

When you take fundus photographs on the same day you perform an HRT test, can you bill for both? Don't answer too quickly, or you could find yourself in deep trouble with insurers.

In 2003, Medicare allowed over 1.5 million charges for fundus photography, reimbursing eye practices over $100 million. To get your fair share, you need to be sure you-re following these diagnostic-procedure coding guidelines.

-Fundus photos are an area a lot of optometrists are overlooking,- says Charles Wimbish, OD, retired optometrist and president of Wimbish Consulting Group in Martinsville, Va. -Photos are good for the patient and Medicare--and good for the office, providing more income. If I were still in practice, I-d be performing 92250 several times a day.-

Beware Laser Scanning Bundles

Optometrists often take fundus photographs (92250, Fundus photography with interpretation and report) in tandem with other diagnostic procedures to document a disease process or follow the progress of a disease. But trying to code for all the services performed along with fundus photography can be tricky.

The rules are strict regarding fundus photography with scanning laser imaging such as OCT, HRT or GDx. The National Correct Coding Initiative (NCCI) bundles 92250 and 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) as a mutually exclusive pair, says Jeri O-Connell, CPC, clinical coder at the Massachusetts Eye and Ear Infirmary in Boston. The bundle is marked with a modifier indicator of -1,- meaning you may be able to report them together by appending a modifier to 92135, as long as your documentation supports the necessity of both.

Experts warn: Many carriers, including Palmetto, Empire (the Part B carrier for New Jersey and part of New York), HealthNow (upstate New York), CIGNA (Idaho, North Carolina and Tennessee) and Blue Cross and Blue Shield of Kansas (Kansas, Nebraska and northwest Missouri), have LCDs for 92135 explicitly saying that 92250 -would generally not be necessary with SCODI. When needed the same day, documentation must support the procedures.-

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. In this case, the diagnosis would need to be very carefully assigned 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.

VF Changes May Justify 92225 With 92250

Carriers have different rules regarding extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) when performed with fundus photography.

Problem: While no longer bundled by NCCI, these two codes represent potentially redundant procedures. Some carriers bundle the payment for fundus photography into the payment for the extended ophthalmoscopy. For example, Triple-S may deny the EO -as not medically necessary if it is anticipated that no new additional information, above that available from the photography, will be obtained.- Tufts, an HMO in Massachusetts, will always deny 92225 or 92226 (... subsequent) as included in 92250.

Solution: Check your carrier for an LCD; if the carrier doesn't state otherwise, you should be able to bill both separately without appending modifier 59 (Distinct procedural service).

-Modifier 59 is a Medicare-only code, so it is not a factor when a private carrier is responsible for the patient,- says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

Tip: Many optometrists only report 92225 and 92250 together when they can document a change in the optic disk or retina or a change in the visual fields. Many LCDs support this strategy. For example, Cigna's policy states, -Fundus photographs are not medically necessary simply to document the existence of a condition. Photographs are medically necessary to establish a baseline to judge later if a disease is progressive.-

Another option: Photographing a patient to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy, then comparing that photograph to the patient's clinical appearance four months later, would be acceptable, Cigna says.

Separate Photos, Gonioscopy, VF From E/M

Optometrists routinely perform fundus photography as part of glaucoma evaluations. These examinations also usually include measuring visual acuity, checking the intraocular pressure, gonioscopy, pupil dilation, and visual field examination.

Of these typical components of a glaucoma exam, you can code fundus photography, gonioscopy (92020, Gonioscopy [separate procedure]) and visual field examinations (92081-92083) separately from the E/M or eye examination code. Check with your carrier, however; these services can sometimes have specific frequency limitations.

Note: For more information on E/M visits and testing services, see -Think You Can Bill E/M With Every Test? Think Again- later in this issue.

Avoid Bilateral Photos for Medicare

Medicare considers code 92250 to be inherently bilateral. The relative value units (RVUs) for fundus photography 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.

Do this: Look in column T (-Bilat Surg-) in the Physician Fee Schedule to see if Medicare assumes that a procedure is bilateral. For 92250, there is a -2- in column T, which means 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.