Medicare Reimbursement for Fundus Photography with Pictor Plus and iNview (Volk Optical)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR FUNDUS PHOTOGRAPHY WITH PICTOR PLUS and iNview
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Q What are Pictor Plus and iNview?
A Pictor Plus is a portable digital imaging device that provides a variety of imaging capabilities with interchangeable modules. This hand held device is available with two imaging modules for ophthalmic exams: posterior and anterior segment.[i] iNview is a lens that attaches to certain Apple smartphone models with a photosensor to facilitate wide-angle fundus photography.
[i] See Corcoran’s other FAQ on Medicare Reimbursement for External Ocular Photography with Pictor Plus
Q Does Medicare cover fundus photography with Pictor Plus and iNview?
A Yes. Medicare will reimburse you for fundus photography if the patient presents with a complaint that leads you to 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 disease is identified). Also, it is not covered if performed for indications not in the local coverage policy.
Q What CPT code should we use to describe fundus photography with Pictor Plus and iNview?
A Use CPT code 92250, Fundus photography with interpretation and report, to report this diagnostic test.
Q What documentation is required in the medical record?
A In addition to the photos or proof that digital images exist, the chart should contain:
- an order for the test with medical rationale
- the date of the test
- the reliability of the test (e.g., cloudy due to cataract)
- the test findings (e.g., hemorrhage, drusen)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the signature of the physician
Q What is the Medicare 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 $67. Of this amount, $45 is assigned to the technical component and $22 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.
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 with Pictor Plus or iNview bundled with other tests or services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92250 is bundled with ICG (92240) and mutually exclusive with scanning computerized ophthalmic diagnostic imaging of the posterior segment (92133, 92134).
Q Must the physician be present while the test is being performed?
A No. Under the 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.
Q How often may testing with Pictor Plus or iNview be repeated?
A There are no published limitations for repeated testing. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from Medicare and other third party payers.
Q Can Pictor Plus or iNview be used in telemedicine?
A Yes. However, doing so requires different CPT codes (92227, 92228), and has different bundles and reimbursement rates.
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 performed in 9% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service about 8 times. For optometrists, the utilization rate is 14%.
Q If coverage of fundus photography 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 may have their own waiver forms.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN
Provided Courtesy of Volk Optical, Inc. (440) 942-6161
Last updated January 1, 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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