Medicare Reimbursement for Fundus Photography with epiCam (epipole)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR FUNDUS PHOTOGRAPHY WITH epiCAM

Q What are the special characteristics of the epiCam fundus imaging system?

A According to epipole, the epiCam is a handheld, lightweight, portable non-mydriatic fundus camera that can also be used on patients who are dilated. Capable of panning and tilting to a 140o field of view, the epiCam takes real-time video and still images in multi-illuminant modes (deep red, amber, and full color). It connects wirelessly to a Review Station where providers can review, edit, save and export still photos from the videos.

Q What CPT code applies to imaging with the epiCam?

A CPT code 92250 (Fundus photography with interpretation and report) best describes this test. The same code applies, irrespective of the light used to image the fundus.1,2

Q Will Medicare cover this test?

A Sometimes. Medicare covers fundus photography (FP) 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.

Images taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease are considered “screening” and therefore not covered even if disease is identified. Payment is the patient’s responsibility provided proper notice is given. Also, this test is not covered if performed for an indication or diagnosis that is not cited in the local coverage policy. Check with your Medicare Administrative Contractor (MAC) for specific coverage limitations.

Q What documentation is required in the medical record?

A In addition to the physician’s order, medical records must include copies of the images and a physician’s interpretation and report. A brief notation such as “abnormal” does not suffice. Complete charting includes:

an order for the test with medical rationale
the date of the test
the reliability of the test (e.g., cloudy due to cataract)
test findings (e.g., microaneurysm)
a comparison with prior tests (if applicable)
a diagnosis (if possible)
the impact on treatment and prognosis
the physician’s signature

Q Will FP be reimbursed if performed the same day as an eye exam?

A According to Medicare’s National Correct Coding Initiative (NCCI) edits, separate reimbursement is allowed for FP when performed in conjunction with eye exams (except 99211). NCCI edits bundle 92250 with ICG angiography (92240, 92242) and show it as mutually exclusive with SCODI-P (92133, 92134).

Q Is the physician’s presence required while FP is performed?

A No. 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 performance of the procedure.

Q How much does Medicare allow for this test?

A 92250 is defined as “bilateral” so reimbursement is for both eyes. The 2023 national Medicare Physician Fee Schedule allowable is $37.61. Of this amount, $16.60 is assigned to the technical component and $21.01 is the value of the professional component (i.e., interpretation). For non-participating physicians, the national allowable is $35.73, and the limiting charge is $41.09. These amounts are adjusted in each area by local indices. Other payers set their own rates, which may differ significantly from Medicare.

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 How often may FP be repeated on a patient?

A In general, diagnostic tests may be performed and repeated when medically necessary. Many MACs have published policies, although not all. Check your MAC’s LCD for 92250 to see if there are published frequency guidelines in your area.
Repeat fundus photography is necessitated by disease progression, the advent of new disease, or planning for additional surgical treatment (e.g., laser). Otherwise, repeated photos of the same, unchanged, condition are unwarranted.

Q What is the frequency of FP in the Medicare program?

A Medicare utilization rates for claims paid in 2018 show that FP was associated with 10% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 10 times. For optometrists, the utilization rate is about 15%.

Q If coverage is unlikely or uncertain, how should we proceed?

A Explain to the patient why fundus 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.

1 CPT Assistant. April 1999. p.10
2 CPT Assistant. Coding Clarification: Special Ophthalmological Services (92133, 92134). Nov. 2014. p.10

Provided Courtesy of epipole

Last updated March 28, 2023

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.

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