Medicare Reimbursement for External Ocular Photography (Topcon Medical Systems)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR EXTERNAL OCULAR PHOTOGRAPHY
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q What is external ocular photography?
A External ocular photography documents medical progress of the external eye, lids and ocular adnexa. Photographs record conditions and pathology of the adnexa, external eye and anterior segment more accurately than chart notes or drawings. They are used to track changes in patients’ abnormal conditions over time.
Q What diagnoses support a claim for external ocular photography?
A Medicare LCDs contain a variety of valid diagnoses for external ocular photos. The lists vary, but usually include diagnoses related to external and anterior segment diseases involving the lids, lacrimal system, cornea, conjunctiva, anterior chamber and iris.
Q What documentation is required in the medical record?
A In addition to the photos or proof that digital images exist, the chart should contain:
- An order for the test with medical rationale
- The date of the test
- The reliability of the test (e.g., patient cooperation)
- The test findings (e.g., vascularization, opacity, defect, dellen, dendrites, neoplasm)
- Comparison with prior tests (when applicable)
- A diagnosis (if possible)
- The impact on treatment and prognosis
- Signature of the physician, and date
Q Does Medicare cover this test?
A Sometimes. The key points that justify coverage include:
- The photographs provide additional information not obtained during the exam
- The photographs aid in diagnosis and treatment of a disease or condition
- The photography are taken to assist in assessing disease progression
Photographs that are taken merely to document disease are typically treated as an incidental part of an exam and not separately reimbursement.
Q Must the physician be present while this test is being performed?
A Under Medicare program standards, this test needs only general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Other payers generally agree.
Q What CPT code is used to describe external ocular photography?
A CPT code 92285, External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, gonio-photography, stereo-photography), describes this service. For tear film imaging, CPT instructs providers to use 0330T. Use 0507T for near-infrared light meibomography.
Q What does Medicare allow for external ocular photography?
A CPT 92285 is defined as “bilateral” so reimbursement is for both eyes. The 2018 national Medicare Physician Fee Schedule allowable for 92285 is $21.24. Of this amount, $18.00 is assigned to the technical component and $3.24 is the value of the professional component (i.e., interpretation). Medicare allowable amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.
92285 is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.
Q Is external ocular photography bundled with other services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92285 is bundled with the surgical codes for blepharoplasty procedures (CPT 15820-15824). Both gonioscopy (92020) and the technician exam (CPT 99211), are bundled with 92285.
Q What is the frequency of external ocular photography in the Medicare program?
A Medicare utilization rates for claims paid in 2016 show that external ocular photography was associated with about 1% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 1 time. The utilization rate for optometry is about the same.
Q How often may external ocular photography be repeated?
A There are no national limitations for repeated testing. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from Medicare and other third party payers.
Q If Medicare or other payer does not cover external ocular photography, may we charge the patient?
A Sometimes. Explain why the test is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN form.
For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
Provided Courtesy of Topcon Medical Systems (800) 223-1130
Last updated July 1, 2018
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over
time, and may be incorrect at any time following publication.
© 2018 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com