Medicare Policy on Screening Fundus Photography (Nidek)
FREQUENTLY ASKED QUESTIONS
Medicare Reimbursement for Fundus Photography
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A: Sometimes. Medicare covers fundus photography 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.
CPT code 92250 (Fundus photography with interpretation and report) best describes this test.
If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then it is not covered (even if disease is identified). Also, this test is not covered if performed for an indication that is not cited in the local coverage policy. Check with your Medicare administrative contractor (MAC) for specific coverage limitations.
Q: If the patient pays for a screening photo and pathology is found, may a claim be submitted to Medicare?
A: No. Under Medicare rules, screening services are not covered, even if a medical problem is found on review of the test.
Q: If the patient does not pay for a screening photo and pathology is found, may a claim be submitted to Medicare?
A: No, you may not file a claim for reim-bursement when the service was free. Screening fundus photos cannot be reimbursed under any circumstances, without regard to the outcome of the test. You may not choose to charge just because pathology was found.
Q: If we perform screening fundus photos and find pathology, when are additional fundus photos warranted?
A: Additional fundus photos are merited at a later point in time when an eye exam finds the condition or disease in the fundus has progressed, and the prior photos no longer depict the pathology at the present time. Having the patient return to re-image for the purposes of submitting a claim is inappropriate; repeated fundus photos of the same disease or condition, without any meaningful change, are not justified.
Q: What are the attributes of a screening program?
A: Screening is differentiated from other diagnostic testing by several features.
- Screening is part of a wellness program to check for disease that may otherwise go undetected.
- Screening is not required by medical necessity; it’s optional.
- The ophthalmologist or optometrist recommends a screening fundus photo prior to every complete eye examination.
- The screening fundus photo is performed by a technician before the patient is seen by the ophthalmologist or optometrist.
- All patients are screened unless they decline.
Q: Why do some cameras have two modes: screening and medical?
A: Screening modules are designed for easy, rapid detection of pathology and provide much less detail than a medical module. By design, the camera system has two distinct functionalities that are distinguished by a significant difference in resolution, as well as other analytical features. Note that no special module is required; any camera may be used for screening.
Q: If a high resolution photo is taken on the same day as a low resolution screening photo, is a claim warranted?
A: Rarely. Occasionally, a detailed photographic study of a disease or condition is ordered subsequent to detection by a screening fundus photo. In this situation, the low resolution photos are replaced by the high resolution photos and a solitary charge is made for the more expansive service. A claim for high resolution photos is justified; the charge for the screening photos is not.
Q: Does analysis of a photo justify an additional charge?
A: There are two parts to a fundus photograph: 1) technical, 2) professional. The technical part is the photographic image. The professional part is the interpretation of the image by the physician. Each part merits a charge, although it is customary to combine them in a single fee when both parts are provided by the same health care enterprise. It is important to note that there is no value to fundus photographs that are not interpreted, and there is potential malpractice risk if the physician fails to interpret the photos.
Q: Do Medicare’s regulations regarding fundus photography apply to both ophthalmologists and optometrists?
A: Absolutely. Medicare rules apply to “physicians”, which include both ophthalmologists and optometrists.
Q: What documentation is required in the medical record?
A: In addition to the images or a reference to where they are stored, the chart notes should contain the following.
- The patient’s name and date of the test
- Appropriate chart notes about the results
- Physician’s signature and date
Appropriate documentation includes interpretation of the test results, a notation of the findings, and assessment. When the results do not identify pathology or abnormalities, it is sufficient to note “normal fundus”. When screening does reveal disease or abnormality, a more extensive note is warranted: findings, impression and/or diagnosis.
Q: Do other third party payers follow Medicare’s coverage and payment policies?
A: Many do, but not all. Other payers are under no obligation to mimic or adhere to Medicare’s concepts, notions or policies. Check with the health plan for coverage information.
Q: How do we document the patient’s acceptance of financial responsibility for screening photos?
A: Since screening tests are statutorily non-covered by Medicare, an Advance Beneficiary Notice of Noncoverage (ABN) form is not required. To avoid confusion, we recommend using a Notice of Exclusion from Healthplan Benefits (NEHB) instead. This also works for commercial plans.
Unfortunately, for patients enrolled in Medicare Advantage (MA) plans (Medicare Part C) you may be required to get a prior determination of noncoverage from the MA plan. Check with the individual plans for their instructions.
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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