Medicare Reimbursement for Fundus Photography with the Clarus 500 (Zeiss)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR FUNDUS PHOTOGRAPHY WITH THE CLARUS 500
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Q: What is the CLARUS 500 ultra-widefield fundus imaging system, and what is it used for?
A: ZEISS notes that the “CLARUS 500 is used to conduct comprehensive fundus examinations, and as an aid in disease diagnosis and management”. They further note it has ultra-widefield capability (up to 133 degrees of view with a single image) and can image via color, infrared, and fundus autofluorescence (FAF, both blue and green). It has stereo capability as well as the ability to montage 2/more images to display up to 266 degrees, measured from center of the eye, at once.1
Following an eye exam that identifies an abnormal condition in the fundus, imaging with the CLARUS 500 may be warranted as a means of further evaluating serious pathology.
CPT code 92250 (Fundus photography with interpretation and report) best describes this test irrespective of the spectrum used to image the fundus.2,3
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. 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 “screening” and therefore not covered even if disease is identified; payment is then 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.1,2
Q: What documentation is required in the medical record?
A: In addition to a physician’s order, a physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images and their location, 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
Q: Will FP be reimbursed if performed on the same day as an eye exam or another diagnostic test?
A: According to Medicare’s National Correct Coding Initiative (NCCI) edits, separate reimbursement is allowed for FP when performed in conjunction with exams (except 99211). The NCCI edits also 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 fundus photography with CLARUS 500 is being performed?
A: Under the Medicare program stan-dards, 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 much does Medicare allow for this test?
A: 92250 is defined as “bilateral” so reimbursement is for both eyes. The 2019 national Medicare Physician Fee Schedule allowable is $51.54. Of this amount, $29.19 is assigned to the technical component and $22.34 is the value of the professional component (i.e., interpretation). For non-participating physicians, the national allowable is $48.96, and the limiting charge is $56.30. 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: 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 2017 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 9 times. For optometrists, the utilization rate is about 14%.
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 ZEISS
Last updated April 16, 2019
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, etc. 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. 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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