Reimbursement for Fundus and Autofluoresence Photography (Canon)
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Reimbursement for Fundus and Autofluoresence Photography
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Q What is fundus photography performed with Canon’s retinal cameras?
A Photographs of the macula, retina and optic nerve, with or without colored filters, are fundus photographs. The posterior pole can be photographed directly through the pupil, with or without mydriasis. Fundus photographs permit a longer look at the back of the eye than is possible with ophthalmoscopy, and an aid in evaluating and monitoring disease.
Q What documentation is required in the medical record?
A In addition to proof that digital images exist, the chart should contain:
- order for the test with medical rationale
- date of the test
- reliability of the test (e.g., cloudy due to cataract)
- test findings (e.g., retinal hemorrhages)
- comparison with prior tests (if applicable)
- a diagnosis, if possible
- the impact on treatment and prognosis
- physician’s signature
Q Does Medicare cover fundus and autofluorescence photography?
A Medicare covers fundus photography if the patient presents with a complaint that leads you to perform this test or as an adjunct to management and treatment of a known disease; other third party payers generally agree. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then it may not covered (even if disease is identified). Also, this test is not covered if performed for an indication that is not cited in the local coverage policy. Local policies may vary.
Q What CPT code describes fundus photography?
A Use CPT code 92250 (Fundus photo-graphy with interpretation and report) to report this service. It is important to note that CPT 92250 describes one or more images taken with the fundus camera, with or without filters. According to the December, 2014, issue of CPT Assistant, AF is described by CPT 92250 either as part of a series of fundus images or as a stand-alone service.1 It is inappropriate to use another CPT code (such as 92499, Unlisted ophthalmologic service or procedure).
A single charge of 92250 applies not matter how many different fundus images are taken on the date of service. Additionally, payers would expect all fundus photography types (color, red-free, or AF) to be done on the same day.
Q What is the reimbursement for 92250?
A CPT 92250 is defined as bilateral so reimbursement is for both eyes. The 2017 national Medicare Physician Fee Schedule allowable is $66.75, including $44.50 for the technical com-ponent and $22.25 for the professional component (i.e., interpretation). These 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.
92250 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 fundus photography bundled with other tests or services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92250 is mutually exclusive with scanning computerized ophthalmic diagnostic imaging of the posterior segment (92133, 92134). It is also bundled with ICG angiography (92240) and the new code for concurrent ICG and fluorescein angiography (92242), although it is not bundled with fluorescein angiography (92235). Some Medicare Administrative Contractors (MACs) also discourage both fundus photography and extended ophthalmoscopy at the same session unless the services are clearly not duplicative.
Q Must the physician be present while the 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 How often may fundus photography be repeated?
A There are no nationally published limitations for repeated testing. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for repeat testing is always required. Too-frequent testing may garner unwanted attention from payers.
Q What is the frequency of fundus photography in the Medicare pro-gram?
A Medicare utilization rates for claims paid in 2015 show that fundus photography was associated with 9% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 9 times. For optometrists, the utilization rate is about 14%.
Q May I ever bill the Medicare beneficiary directly for this service?
A Sometimes. Explain to the patient 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.
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.
For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
For Part C Medicare (Medicare Advantage), a determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered or potentially noncovered services. MA Plans might have their own process and forms; be sure to check.
1 CPT Assistant. December 2015, Volume 254 Issue 12). Medicine: Ophthalmology.
Provided Courtesy of Canon USA, Inc. (800) 970-7227
Last updated March 10, 2017
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and 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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