Medicare Reimbursement for External Photography with Pictor Plus(Volk Optical)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR EXTERNAL PHOTOGRAPHY WITH PICTOR PLUS

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Q  What is Pictor Plus?

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.[1]


[1]   See Corcoran’s other FAQ on Medicare Reimbursement for Fundus Photography with Pictor Plus and iNview

 

Q  What is external ocular photography?

A  External ocular photography images the anterior segment, external eye, and ocular adnexa.  Photographs can elucidate abnormalities of these structures more clearly than chart notes or drawings.  Photographs are used to identify changes in patients’ conditions over time.

 

Q  What CPT code should we use to describe external ocular photography with Pictor Plus?

A  CPT code 92285, External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, stereo-photography, describes this service.

 

Q  What diagnoses support reimbursement for external ocular photography?

A  Most Medicare LCDs contain a variety of acceptable diagnoses for external photos.  The lists vary, but usually include diagnoses related to the external adnexa and anterior segment.

 

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
  • the test findings (e.g., dendrites, neoplasm)
  • comparison with prior test (if applicable)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • the signature of the physician

 

 

Q  Does Medicare cover external ocular photography with Pictor Plus?

A Sometimes.  The key points that justify coverage include:

  • The photographs provide additional information not obtained during the exam
  • The photographs aid in diagnosis and treatment of a disease or condition
  • The photography are taken to assist in assessing disease progression

Photographs that are taken merely to document disease are typically treated as an incidental service and not accorded separate reimbursement

 

Q  Must the physician be present while this test is 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  What does Medicare allow for external ocular photography with Pictor Plus?

A CPT 92285 is defined as “bilateral” so reimbursement is for both eyes.  The 2017 national Medicare Physician Fee Schedule allowable for 92285 is $21. Of this amount, $18 is assigned to the technical component and $3 is the value of the professional component (i.e., interpretation).  Medicare allowable 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.

External ocular 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  What is the frequency of external ocular photography in the Medicare program?

A  Medicare utilization rates for claims paid in 2014 show that external photography was performed at 1% of all office visits by ophthalmologists.  That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 1 time.  The utilization rate for optometry is about the same.

 

Q  How often may external ocular photography with Pictor Plus be repeated?

A  There are no national limitations for repeated testing, although some Medicare contractors may publish local policies.  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  Is external ocular photography with Pictor Plus bundled with other services?

A  Yes.  According to Medicare’s National Correct Coding Initiative (NCCI), 92285 is bundled with the surgical codes for blepharoplasty procedures (CPT 15820-15824).  Both gonioscopy (92020) and the level 1 established patient E/M code, known as the “technician exam” (CPT 99211), are bundled with external photos.  When these services are performed together, the claim for the external photos will be honored; the concurrent claims for 92020 or 99211 will be denied.

 

Q  If coverage of external ocular photography is unlikely or uncertain, how should we proceed? 

A Explain to the patient why external 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.

 

© 2017 Corcoran Consulting Group.   All rights reserved.  No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher.

 

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