Medicare Reimbursement for External Photography (Nidek)

FREQUENTLY ASKED QUESTIONS

Medicare Reimbursement for External Photography

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Q: What is external photography?

A: External photography documents the external eye, lids and ocular adnexa. Photographs can 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’ conditions over time.

Q: What CPT code should we use to describe this test?

A: CPT code 92285 (External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, stereo-photography) describes this service.

Q: What diagnoses support a claim for external photography?

A: Most Medicare LCDs contain a variety of valid diagnoses for external 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: Is the physician’s presence required while external photography is being performed?

A: Under Medicare program standards, this test requires 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 test.

Q: What documentation is required in the medical record to support claims for external photography?

A: A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images or a reference to where they are stored, the medical record should include:

order for the test with medical rationale
date of the test
the reliability of the test (e.g., patient cooperation)
test findings (e.g., vascularization, opacity, defect, dellen, dendrites)
comparison with prior tests (if applicable)
a diagnosis (if possible)
the impact on treatment and prognosis
physician’s signature and date

A form suitable for documenting the interpretation of fundus photos and other tests is available on our website. It may also be adapted for use within an EMR system.

Q: Does Medicare cover external photography performed with Nidek’s AFC-330?

A: Sometimes; the key points that warrant 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 service and not accorded separate reimbursement.

Q: What does Medicare allow for external 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 fee schedule 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.

External photography 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: What is the frequency of external photography in the Medicare program?

A: Medicare utilization rates for claims paid in 2016 show that external photography was performed at 1.2% of all office visits by ophthalmologists. That is, for every 1,000 exams and consultations performed on Medicare beneficiaries, Medicare paid for this service 12 times. The utilization rate for optometry is 1.4%.

Q: How often may this test be repeated?

A: In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.

Q: Is external photography bundled with other services?

A: Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92285 is bundled with the eyelid surgery codes 15820-15823.

Both gonioscopy (92020) and the technician exam (CPT 99211) are bundled with external photos.

Q: If coverage of external photography is unlikely or uncertain, how should we proceed?

A: Explain to the patient why external photography 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 Nidek (800) 223-9044

Last updated April 24, 2018

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

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