Fundus Photography CPT code 92250, 92499 and Valid diagnosis code – Fee amount

Procedure Description

92250 Eye exam with photos – Average fee payment $ 82

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.

 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

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.

CPT/HCPCS Codes

Billing and Coding Guidelines


The below CPT codes would be bundled if submitted with CPT 92250, avoid that submit with Modifier 92227 and 99211

It should be noted that there are National Correct Coding Initiative (NCCI) mutually exclusive edits for CPT codes 92135 and 92250.   A modifier is allowed if performed on separate eyes.  However, CPT code 92250 has a bilateral indicator of “2’ on the Medicare Physician Fee Schedule Database.  Therefore, the fee schedule amount represents photography of both eyes.  Modifier ‐52 should be appended if only one eye is photographed.

Performing Fundus Photography and SCODI on the Same Day on the Same Eye: Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133 or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250 (National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology).


Intraocular Photography (also known as Fundus Photography)

a. Intraocular Photography to Diagnose Conditions listed below (CPT code 92250) Intraocular photography when used by an ophthalmologist is covered for the diagnosis of
such conditions as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, or to identify glaucoma, multiple sclerosis and other central nervous system abnormalities.

Applicable service codes: 92250

CPT Code 92250 is a bilateral procedure and should be billed only once.



ICD-10 Diagnoses codes: H52.00, H52.01, H52.02, H52.03, H52.10, H52.11, H52.12, H52.13, H52.201, H52.202, H52.203, H52.209, H52.211, H52.212, H52.213, H52.219, H52.221, H52.222, H52.223, H52.229, H52.31, H52.32, H52.4, H52.511, H52.512, H52.513, H52.519, H52.521, H52.522, H52.523,H52.529, H52.531, H52.532, H52.533, H52.539, H52.6, H52.7, Z83.3, Z83.511, Z83.518, Z01.00, Z01.01

 Limitations

    • Fundus photography is considered medically reasonable and necessary when it is furnished by a qualified optometrist or ophthalmologist in the course of the evaluation and management of a retinal disorder or another condition that has affected the retina as outlined above. Therefore, the digital imaging systems for the detection and evaluation of diabetic retinopathy used to acquire retinal images through a dilated pupil with remote interpretation do not meet reasonableness and necessity criteria for fundus photography (CPT codes 92227 and 92228).

    • Performing Fundus Photography and SCODI on the Same Day on the Same Eye

    Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133 or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59-distinct procedural service or HCPCS modifier XU-unusual, non-overlapping service to CPT code 92250 (National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology).

    The physician is not precluded from performing fundus photography and posterior segment SCODI on the same eye on the same day under appropriate circumstances (i.e., when each service is necessary to evaluate and treat the patient.


   ICD-10 Codes that Support Medical Necessity
 
    B20 Human immunodeficiency virus [HIV] disease
    B39.4 Histoplasmosis capsulati, unspecified
    B39.9 Histoplasmosis, unspecified
    B58.01 Toxoplasma chorioretinitis
    C69.00 Malignant neoplasm of unspecified conjunctiva
    C69.01 Malignant neoplasm of right conjunctiva
    C69.02 Malignant neoplasm of left conjunctiva
    C69.10 Malignant neoplasm of unspecified cornea
    C69.11 Malignant neoplasm of right cornea
    C69.12 Malignant neoplasm of left cornea
    C69.20 Malignant neoplasm of unspecified retina
    C69.21 Malignant neoplasm of right retina
    C69.22 Malignant neoplasm of left retina
    C69.30 Malignant neoplasm of unspecified choroid
    C69.31 Malignant neoplasm of right choroid
    C69.32 Malignant neoplasm of left choroid
    C69.40 Malignant neoplasm of unspecified ciliary body
    C69.41 Malignant neoplasm of right ciliary body
    C69.42 Malignant neoplasm of left ciliary body
    C69.50 Malignant neoplasm of unspecified lacrimal gland and duct
    C69.51 Malignant neoplasm of right lacrimal gland and duct
    C69.52 Malignant neoplasm of left lacrimal gland and duct
    C69.60 Malignant neoplasm of unspecified orbit
    C69.61 Malignant neoplasm of right orbit
    C69.62 Malignant neoplasm of left orbit
    C69.80 Malignant neoplasm of overlapping sites of unspecified eye and adnexa
    C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa
    C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa
    C69.90 Malignant neoplasm of unspecified site of unspecified eye
    C69.91 Malignant neoplasm of unspecified site of right eye
    C69.92 Malignant neoplasm of unspecified site of left eye
    D09.20 Carcinoma in situ of unspecified eye
    D09.21 Carcinoma in situ of right eye
    D09.22 Carcinoma in situ of left eye
    D18.09 Hemangioma of other sites
    D31.20 Benign neoplasm of unspecified retina
    D31.21 Benign neoplasm of right retina
    D31.22 Benign neoplasm of left retina
    D31.30 Benign neoplasm of unspecified choroid
    D31.31 Benign neoplasm of right choroid
    D31.32 Benign neoplasm of left choroid
    D48.7 Neoplasm of uncertain behavior of other specified sites
    D49.81 Neoplasm of unspecified behavior of retina and choroid
    D49.89 Neoplasm of unspecified behavior of other specified sites
    D57.00 Hb-SS disease with crisis, unspecified
    D57.01 Hb-SS disease with acute chest syndrome
    D57.02 Hb-SS disease with splenic sequestration
    D57.1 Sickle-cell disease without crisis
    D57.20 Sickle-cell/Hb-C disease without crisis
    D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
    D57.212 Sickle-cell/Hb-C disease with splenic sequestration
    D57.219 Sickle-cell/Hb-C disease with crisis, unspecified
    D57.80 Other sickle-cell disorders without crisis
    D57.811 Other sickle-cell disorders with acute chest syndrome
    D57.812 Other sickle-cell disorders with splenic sequestration
    D57.819 Other sickle-cell disorders with crisis, unspecified
    E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
    E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
    E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
    E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
    E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
    E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
    E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
    E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
    E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
    E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
    E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
    E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
    E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
    E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
    E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
    E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
    E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
    E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
    E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
    E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
    E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
    E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
    E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
    E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
    E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
    E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
    E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
    E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
    E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
    E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
    E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
    E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
    E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye





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:

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.

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:

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