Article Date: 5/1/2003

coding q & a
Rules for Fundus Photography
See what Medicare has to say about billing, documentation and frequency.
By Suzanne Corcoran, C.O.E.

Q  Does Medicare cover fundus photography?

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. If you take the images as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then Medicare won't cover it (even if you identify a disease). Medicare also won't cover this test if you perform it for an indication that isn't cited in the local medical review policy. Check with your carrier for specific coverage limitations.

Use CPT code 92250 (fundus photography with interpretation and report) to bill for this test.

What is the reimbursement for 92250?

This code is defined as "bilateral" so you get reimbursed for both eyes. The 2003 national Medicare fee schedule allowable is $71.73. Of this amount, $47.82 is assigned to the technical component and $23.91 to the professional component (i.e., interpretation).

These amounts are adjusted in each area by local indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Is fundus photography bundled with an office visit or consultation?

According to Medicare's National Correct Coding Initiative, 92250 isn't bundled with an eye exam or consultation. That means that you can bill for an office visit or consultation on the same day that you bill for a fundus photograph. The code chosen for the visit will, as always, be based on what was included in the exam and on the patient's complaints.

What documentation is required in the medical record?

In addition to the photos or proof that digital images exist, the chart should contain:

Must I be present while a tech performs the test?

Under the Medicare program standards, this test only requires general supervision. That means the procedure is furnished under the doctor's overall direction and control, but the doctor's presence is not required during the performance of the procedure. The doctor's interpretation of the test should be done within a short time of the photos being taken. Too long a delay would bring the medical necessity for the test into question.

How often can you repeat this test?

No limitations for repeated testing are published. 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. 

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.


Optometric Management, Issue: May 2003