Reimbursement for Fundus and Autofluoresence Photography (Canon)

FREQUENTLY ASKED QUESTIONS:

Reimbursement for Fundus and Autofluoresence Photography

For best results, please view in Mozilla Firefox.

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 photography 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 2019 national Medicare Physician Fee Schedule participating allowable is $51.54, including $29.19 for the technical component and $22.34 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 program?

A Medicare utilization rates for claims paid in 2016 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. 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 forms and 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.

¹ CPT Assistant. December 2015, Volume 254 Issue 12. Medicine: Ophthalmology.

Provided Courtesy of Canon USA, Inc. (800) 970-7227

Last updated February 18, 2019

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.

© 2019 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