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2011 Medicare Reimbursement for Fundus Photography Now Available!


Saturday, June 18, 2011

Fundus Photography CPT code 92250, 92499 and Valid diagnosis code

Fundus photography requires a camera using film or digital media to photograph structures behind the lens of the eye. Near photo-quality images are also obtainable utilizing scanning laser equipment with specialized software. (See the “CPT/HCPCS” section of this LCD and the “Coding Guidelines” section of the LCD Article for coding instructions.)
In order to document a disease process, plan its treatment or follow the progress of a disease, fundus photographs may be necessary. Fundus photographs are not medically necessary simply to document the existence of a condition. However, photographs may be medically necessary to establish a baseline to judge later whether a disease is progressive. Examples are as follows:
  • It does not add to the patient’s care to photograph dry age-related maculopathy to document its existence.
  • Fundus photography may be necessary to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy. In four to six months, the baseline photograph can be compared to the clinical appearance of the current diabetic retinal edema to see if it is progressing to clinically significant diabetic macular edema. This information can be used to decide whether or not to advise the patient to undergo focal laser photocoagulation.
The intent of these examples is to point out how in the former there is not a therapeutic decision being made, while in the latter there is. The fundus photography should aid in making a clinical decision.

Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
Fundus photography is not a covered service when used to document the absence of pathology (i.e., a normal or healthy fundus or screening) or when the physician elects to incorporate it as a routine procedure. Routine fundus photography for purposes other than documentation, monitoring and treatment of a pathological process falls outside the standard of care as a medical necessity and is thereby not a covered service.
Some organizations recommend that diabetics have an annual dilated eye examination to look for retinal disease; fundus photographs are not an acceptable substitute for the dilated eye exam.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual – (IOM) Pub. 100-04, Claims Processing Manual, – forfurther guidance.
0920
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
92250©
Eye exam with photos

Note: Use 92250 only to report photographs obtained with a camera on film or digital media.
Unlisted ophthalmological service or procedure

Note: Use 92499 to identify fundus images obtained with scanning laser equipment.
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 92250 and 92499 (when used to identify fundus images obtained with scanning laser equipment):
Covered for:
017.30–017.36
Tuberculosis of eye
042
Human immunodeficiency virus (hiv) disease
078.5
Cytomegaloviral disease
091.51
Syphilitic chorioretinitis (secondary)
094.83
Syphilitic disseminated retinochoroiditis
115.02
Histoplasma capsulatum retinitis
115.92
Histoplasmosis, unspecified, retinitis
130.0
Meningoencephalitis due to toxoplasmosis
130.2
Chorioretinitis due to toxoplasmosis
130.9
Toxoplasmosis unspecified
190.5–190.6
Malignant neoplasm of eye
198.4
Secondary malignant neoplasm of other parts of nervous system
224.0
Benign neoplasm of eyeball except conjunctiva cornea retina and choroid
224.5–224.6
Benign neoplasm of eye
225.1
Benign neoplasm of cranial nerves
238.8–238.9
Neoplasm of uncertain behavior of other and unspecified sites and tissues
250.50–250.51
Diabetes with ophthalmic manifestations
264.7
Other ocular manifestations of vitamin a deficiency
270.2
Disorders of amino acid transport and metabolism; other disturbances of aromatic amino acid metabolism
340
Multiple sclerosis
348.2
Benign intracranial hypertension
360.00–360.04
Purulent endophthalmitis
360.11–360.14
Other endophthalmitis
360.19
Other endophthalmitis
360.20–360.24
Degenerative disorders of the globe
360.30–360.33
Hypotony of eye
360.43–360.44
Degenerated conditions of the globe
360.50
Disorders of the globe; foreign body, magnetic, intraocular, unspecified
360.54–360.55
Retained (old) intraocular foreign body, magnetic
360.59
Disorders of the globe; intraocular foreign body, magnetic, in other or multiple sites
360.64–360.65
Retained (old) intraocular foreign body, nonmagnetic
360.69
Disorders of the globe; non-magnetic, foreign body in other or multiple sites
361.00–361.07
Retinal detachment with retinal defect
361.10–361.14
Retinoschisis and retinal cysts
361.19
Other retinoschisis and retinal cysts
361.2
Retinal detachments and defects; serous retinal detachment
361.30–361.33
Retinal defects without detachment
361.81
Traction detachment of retina
361.89
Other forms of retinal detachment
361.9
Unspecified retinal detachment
362.01–362.07
Diabetic retinopathy
362.10–362.18
Other background retinopathy and retinal vascular changes
362.20–362.27
Other proliferative retinopathy
362.29
Other non-diabetic proliferative retinopathy
362.30–362.37
Retinal vascular occlusion
362.40–362.43
Separation of retinal layers
362.50–362.57
Degeneration of macula and posterior pole
362.60–362.66
Peripheral retinal degenerations
362.70–362.77
Hereditary retinal dystrophies
362.81–362.85
Other retinal disorders
362.89
Other retinal disorders
362.9
Other retinal disorders; unspecified retinal disorder
363.00–363.01
Focal chorioretinitis and focal retinochoroiditis
363.03–363.08
Focal chorioretinitis and focal retinochoroiditis
363.10–363.15
Disseminated chorioretinitis and disseminated retinochoroiditis
363.20–363.22
Other and unspecified forms of chorioretinitis and retinochoroiditis
363.30–363.35
Chorioretinal scars
363.40–363.43
Choroidal degenerations
363.50–363.57
Hereditary choroidal dystrophies
363.61–363.63
Choroidal hemorrhage and rupture
363.70–363.72
Choroidal detachment
363.8–363.9
Other disorders of choroid
365.00–365.04
Borderline glaucoma [glaucoma suspect]
365.10–365.15
Open angle glaucoma
365.20–365.24
Primary angle-closure glaucoma
365.31–365.32
Corticosteroid-induced glaucoma
365.41–365.44
Glaucoma associated with congenital anomalies, dystrophies and systemic syndromes
365.51–365.52
Glaucoma associated with disorders of the lens
365.59
Glaucoma associated with other lens disorders
365.60–365.65
Glaucoma associated with other ocular disorders
365.81–365.83
Other specified forms of glaucoma
365.89
Other specified forms of glaucoma
365.9
Glaucoma, unspecified
368.54
Achromatopsia
368.61
Congenital night blindness
377.00–377.04
Disorders of optic nerve and visual pathways; papilledema
377.10–377.16
Disorders of optic nerve and visual pathways; optic atrophy
377.21–377.24
Disorders of optic nerve and visual pathways; other disorders of optic disc
377.30–377.34
Disorders of optic nerve and visual pathways; optic neuritis
377.39
Disorders of optic nerve and visual pathways; other optic neuritis
377.41–377.43
Disorders of optic nerve and visual pathways; other disorders of optic nerve
377.49
Disorders of optic nerve and visual pathways; other disorders of optic nerve
379.00
Other disorders of eye; scleritis, unspecified
379.07
Other disorders of eye; posterior scleritis
379.09
Other disorders of eye; other scleritis and episcleritis
379.11
Scleral ectasia
379.21–379.26
Disorders of vitreous body
379.29
Other disorders of vitreous
379.60–379.63
Inflammation (infection) of postprocedural bleb
710.0
Systemic lupus erythematosus
743.51–743.59
Congenital cataract and lens anomalies
759.5–759.6
Other and unspecified congenital anomalies
759.82
Marfan syndrome
771.0
Congenital rubella
871.5–871.6
Open wound of eyeball
950.0–950.1
Injury to optic nerve and pathways
V10.84
Personal history of malignant neoplasm of eye
V58.63
Long-term (current) use of antiplatelets/antithrombotics
V58.64
Long-term (current) use of nonsteroidal anti-inflammatories
V58.65
Long-term (current) use of steroids
V58.69
Encounter for other and unspecified procedures and after care; long-term (current) use of other medications
V67.51
Follow-up examination; following completed treatment with high-risk medication, NEC
Note: Diabetic retinopathy must be coded using appropriate ICD-9-CM codes from 362.0X. Correct coding of 362.0X dictates primary coding with 250.50–250.51, but payment will not occur unless 362.0X is also reported.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
In order to determine medical necessity, a copy of the clinical records which must justify the diagnosis listed on the claim and the reason(s) that fundus photographs and the frequency with which they were repeated were necessary for planning therapy and monitoring the progress of the disease diagnosed may be requested.
Documentation must support the medical necessity of this service as outlined in the “Indications and
Limitations of Coverage and/or Medical Necessity” section of this policy.
Documentation in the patient’s medical record should include all of the following:
  • A current pertinent history and physical examination, and progress notes describing and supporting the covered indication.
  • Pertinent prior diagnostic testing and completed report(s). This would include, when appropriate, previous fundus photographs.
  • The medical record must be made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.