Medicare Reimbursement for Fundus Photography with RHA (Annidis Health Systems)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR FUNDUS PHOTOGRAPHY WITH RHA™
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Q What is the Annidis RHA™ instrument?
A The RHA (Retinal Health Assessment) instrument from Annidis is a digital ophthalmoscope and fundus camera that takes multispectral retinal and subretinal images. The multispectral images (450-950nm) facilitate earlier disease detection. Software allows for presentation of the images in a variety of ways.
Q What CPT code should we use to describe this test, and does Medicare cover it?
A CPT code 92250 (Fundus photography with interpretation and report) best describes this test. Medicare covers fundus photography if the patient presents with a complaint that leads you to do this test or as an adjunct to management and treatment of a known disease. Also, this test is covered if performed for an indication that is cited in the local coverage policy, otherwise it is not covered. Check with your Medicare Administrative Contractor (MAC) for specific coverage limitations in your area.
Q What is the Medicare reimbursement for 92250?
A CPT 92250 is defined as bilateral, so reimbursement is for both eyes. The 2015 national Medicare Physician Fee Schedule allowable is $79. Of this amount, $55 is assigned to the technical component and $24 is the value of the professional component. 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 Is fundus photography 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 What documentation is required in the medical record?
A A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images, 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 (e.g., microaneurysm)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
Q Must the physician be present while the test is being performed?
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 May the RHA be used for screening?
A Yes. The RHA FastScan is ideal for this purpose because it is quicker and less intense than the RHA FullSpectrum. The camera is non-mydriatic; dilation may not be required for many patients.
Screening occurs when images are:
- Part of a wellness program to check for disease that may otherwise go undetected.
- Not required by medical necessity; it’s optional.
- Recommended prior to every complete eye examination.
- Taken before the patient is examined by the eye care provider.
- Done for all patients unless they decline.
Q How are we paid for screening tests?
A Patients must be given the opportunity to choose between an exam with or without RHA FastScan. After the benefits of screening have been explained, the patient is advised of the extra charge for this service; you may ask them to sign a financial waiver form. The patient is financially responsible for non-covered services; no reimbursement from payers is sought.
HCPCS code S9986 “not medically necessary service” is useful for internal recordkeeping, but Medicare and some payers will not accept it for claims. If a beneficiary insists that you file a claim, report 92250-GY. Using the modifier -GY ensures a denial; it means the “Item or service [is] statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit”.
Q If coverage of fundus photography is unlikely or uncertain, how should we proceed?
A EExplain 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.
Q How often may imaging be repeated?
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.
Provided Courtesy of Annidis Health Systems (613) 596-1800
Last updated July 15, 2015
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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