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:

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.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X

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

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):

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

N/A

N/A

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

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:

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.