Wiki Documentation requirements for OPTOS

[jason.lang]

Looking for advice on where to find medical record documentation requirements when billing for the OPTOS. The OPTOS is billed under the same CPT as Fundus Photography 92250 and is being used in most cases as an alternative to being dilated. I'm looking for documentation guidelines / requirements for the medical record when the OPTOS is performed with no findings. Options for a DFE (Dilated Fundus Exam) are explained to the patient by the provider and if a patient defers dilation but elects for the OPTOS an ABN is executed. My concern here is what should the provider be documenting in the medical record when there isn't a medical finding.

I'm leaning toward:

Patient defers dilation - OPTOS 'undilated' photography discussed with the patient
Patient elects to proceed
ABN executed and signed by patient

OPTOS reviewed - unremarkable optic screening without complications noted

Do you think this to be appropriate and pass on review? I've searched the local carrier NGS for guidance as well as CMS with no luck. I've asked the OPTOS folks as well with no luck.

Thanks in advance

 

[dkeown]

I would treat the OPTOS like any other Fundus Photography, since it is being billed under that code (barring a LCD.) The Corcoran Consulting Group has shared the attached, which I find to be helpful.

David Keown, CPC, OCS

 

[Cheezum51]

First of all, just to clarify, Optos is not accepted as an alternative to a dilated fungus exam in regards to standard of care. If your provider were ever sued for malpractice because they missed a retinal pathology and there was no dilation done and Optos substituted, I can tell you that any retinal specialist who testified would state they weren't equivalent and your provider would lose their case. There is case precedence for what I've just stated.

Another issue this brings up is the code you billed for the exam without dilation. Medicare requires dilation for a level 4 99 exam and often for a level 4 92 exam. Several commercial insurers also require dilation for the level 4 exams. Therefore, if the patient isn't dilated and has Medicare or a commercial plan that does require dilation, then you're left having to bill either a level 3 99 code or a level 2 92 code for the exam.

All of that being said, I think your record documentation note above would be sufficient for the patient who had the Optos and had no pathology detected through the imaging process.

The Corcoran reference above is a great reference for using Optos to document a pathology found through a dilated exam and then order the imaging.

Tom Cheezum, OD, CPC, COPC