Medicare Reimbursement for Fundus Photography (Nidek)

FREQUENTLY ASKED QUESTIONS

Medicare Reimbursement for Fundus Photography

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Q: What is fundus photography?

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. Dilation permits sharper and brighter pictures because a larger pupil admits more light. Fundus photographs permit a longer look at the back of the eye than is possible with ophthalmoscopy, and aid in evaluating and monitoring disease.

Q: Is fundus photography performed with Nidek’s AFC-330 and DS-20 covered by Medicare and other payers?

A: Usually. Medicare will reimburse you for fundus photography if the patient presents with a complaint that leads you to order and perform this test as an adjunct to evaluation and management of a covered indication. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then the test is generally not covered (even if the test identifies disease). Also, it is not covered if performed for indications not in the local coverage policy.

Q: What CPT code is used to describe fundus photography?

A: Use CPT code 92250 (Fundus photography with interpretation and report) to report this test.

Q: What documentation is required in the medical record to support a claim for fundus 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., cloudy due to cataract)
test findings (i.e., microaneurysm)
comparison with prior tests (if applicable)
a diagnosis (if possible)
the impact on treatment and prognosis
physician signature

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: How is fundus photography reimbursed?

A: CPT 92250 is defined as bilateral so reimbursement is for both eyes. The 2018 national Medicare Physician Fee Schedule allowable is $58.32. Of this amount, $36.00 is assigned to the technical component and $22.32 is the value of 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.
Fundus 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 Medicare’s supervision requirement for fundus photography?

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 performance of the procedure.

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, 92242). The remote screening retinal test, 92227, is bundled with 92250, as is the technician exam 99211.

Some Medicare Administrative Contractors (MACs) also discourage both fundus photography and extended ophthalmoscopy at the same session unless you can clearly demonstrate that the services are not duplicative.

Q: How often may we repeat this test?

A: 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 or noncovered.

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

A: 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, 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 may have their own waiver forms 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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