Medicare Reimbursement for optomap plus Fundus Photography (Optos)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR optomap® plus FUNDUS PHOTOGRAPHY
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Q What is optomap® plus?
A The optomap plus is an optimized digital image of the fundus acquired by an Optos® retinal imaging device. It permits close study and interpretation of previously identified pathology by a physician. The full color image is high resolution and captures a 200 degree image in a single capture through a dilated or undilated pupil. Using proprietary software, the optomap plus digital image can be reviewed, annotated, and shared with other physicians. According to the company, Optos has cloud storage which fulfills all regulations re-lated to data backup and restoration requirements.
CPT code 92250 (Fundus photography with interpretation and report) best describes this test.
Q What are the indications for optomap plus?
A Following an eye exam that identifies an abnormal condition in the fundus, an optomap plus may be warranted as a means of further evaluating serious pathology.
Q Will Medicare cover this test?
A Usually. 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 based on standing orders, taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then the test is not covered even if disease is identified. 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 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 or a reference to where they are stored, the medical record should include:
- 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 (i.e., microaneurysm)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the signature of the physician
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 Will optomap plus be reimbursed if performed on the same day as an eye exam or another diagnostic test?
A Usually. 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 ophthalmo-scopy at the same session unless you can clearly demonstrate that the services are not duplicative.
Q How much does Medicare allow for this test?
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 The optomap plus also performs autofluorescence; is it separately billed?
A No. CPT 92250 describes one or more images taken with the fundus camera, with or without filters. It is inappropriate to use another CPT code, such as 92499 (Unlisted ophthalmologic service or procedure) in addition to 92250.
Q Should optomap plus be billed on the same day as standard optomap?
A As a general rule, when two similar tests are performed on the same day, only one of them is billed – usually the more extensive test.
Q How often may optomap plus be repeated on a patient?
A Many MACs have published policies, although not all. Check your MAC’s LCD 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.
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 bene-ficiaries, 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 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 Optos, Inc. (800) 854-3039
Last updated June 7, 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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