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.
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.