Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended
Ophthalmoscopy and Fundus Photography)

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34399-Ophthalmology: Posterior Segment
Imaging (Extended Ophthalmoscopy and Fundus Photography).

**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.

**Claims Information:**  
  
All services/procedures performed on the same day for the same beneficiary by
the physician/provider should be billed on the same claim.  
  
 _Extended Ophthalmoscopy_  
  
Codes 92201and 92202 are bilateral codes and do not require  a site modifier
(LT, RT or 50). A claim with one of these modifiers (RT, LT or 50) will be
returned as incomplete. Each service must be billed with an NOS of 001.  
  
Extended ophthalmoscopy is classified as a professional service. The use of
professional or technical component modifiers (26, TC), with these codes, is
not appropriate.  
  
If extended ophthalmoscopy is performed during a global surgery period,
unrelated to the condition for which the surgery was performed (same
provider), then the extended ophthalmoscopy should be coded with a modifier 79
attached (in addition to the appropriate site modifier).  
  
The initial exam for ophthalmoscopy codes (92201 or 92202) may be billed if
the patient has had extended ophthalmoscopy (of the same eye) by the same
physician/physician group within the last three (3) years.  
  
Indirect ophthalmoscopy done without a drawing may not be billed separately
and is part of a general ophthalmologic exam (92002-92014).  
  
Acceptable places of service are office (11), assisted living facility (13),
urgent care (20), inpatient hospital (21), outpatient hospital (22), emergency
room (23), and skilled nursing facility (31), nursing facility (32), custodial
care facility (33), and independent clinic (49).  
  
_Fundus Photography_  
  
CPT codes 92250 and 92228 describe services that are performed bilaterally.
Modifier 50 is never appropriate with these codes. Modifiers LT and RT should
only be used if a unilateral service is performed.  
  
CPT codes 92250 and 92228 are global services, which include a professional
and a technical component. The components should be reported with modifiers 26
or TC as appropriate, if the entire global service is not performed.  
  
CPT code 92227 (Remote imaging for detection of retinal disease (eg,
retinopathy in a patient with diabetes) with analysis and report under
physician supervision, unilateral or bilateral) is considered screening and
will be denied as non-covered. Claims for this service should be submitted
with modifier GY.  
  
Acceptable places of service for the global service are office (11), assisted
living facility (13), urgent care (20), nursing facility for patients in a
Part B stay (32), and independent clinic (49).  
  
The technical component may be billed in office (11), assisted living facility
(13), urgent care (20), nursing facility for patients in a Part B stay (32),
independent clinic (49), federally qualified health center (50), and rural
health clinic (72).  
  
The professional component may be billed in office (11), assisted living
facility (13), urgent care (20), inpatient hospital (21), outpatient hospital
(22), skilled nursing facility for patients in a Part A stay (31), nursing
facility for patients in a Part B stay (32) and independent clinic (49).  
  

**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

_Fundus photography_

The patient's medical record must contain documentation that fully supports
the medical necessity for fundus photography as it is covered by Medicare.
(See "Indications and Limitations of Coverage.") This documentation includes,
but is not limited to, relevant medical history, physical examination, and
results of pertinent diagnostic tests or procedures.  
  
A copy of the fundus photographs must be retained in the patient's medical
records. An interpretation and report of the test must also be included, in
addition to the photographs themselves.  
  
The medical record should document whether the pupil was dilated, and which
drug was used.  
  
Documentation supporting the medical necessity should be legible, maintained
in the patient's record, and must be available to the carrier upon request.  
  
 _Extended ophthalmoscopy_  
The patient's medical record must contain documentation that fully supports
the medical necessity for extended ophthalmoscopy for each eye, as it is
covered by Medicare. (See "Indications and Limitations of Coverage.") This
documentation includes, but is not limited to, relevant medical history,
physical examination, and results of pertinent diagnostic tests or procedures.  
  
Retinal drawings meeting the specifications indicated in the policy must be
maintained in the patient's record.

  * There must be a separate detailed sketch, minimal size of 3-4 inches.
  * All items noted must be identified and labeled.
  * Drawings in four (4) - six (6) standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.
  * Optic nerve abnormalities should be separately drawn.
  * An extensive scaled drawing must accurately represent normal, abnormal and common findings such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears or tumors.

Documentation in the patient's medical record for a diagnosis of glaucoma must
include all of the following:

  * A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment,
  * Documentation of cupping, disc rim, pallor, and slope,
  * Documentation of any surrounding pathology around the optic nerve.

Documentation specific to the method of examination (e.g., lens, scleral
depression, instrument used) should be maintained in the medical record.  
  
The medical record should document whether the pupil was dilated, and which
drug was used.  
  
All findings and a plan of action should be documented in notes.  
  
Although routine ophthalmoscopy and biomicroscopy are part of an
ophthalmologic examination and are not separately payable, these should still
be documented in the patient's medical record.  
  
Documentation supporting the medical necessity should be legible, maintained
in the patient's record, and must be available to the carrier upon request.  
  
Patients actively being treated with intravitreal injections of medication for
exudative AMD (ICD-10-CM code H35.32) may require up to 12 extended
ophthalmoscopies per eye, per year.  
  
Conditions coded with other ICD-10-CM* codes may require up to six (6)
extended ophthalmoscopic examinations per eye, per year. (See list below)  
  
For ICD-10-CM codes C69.41-C69.42, C69.21-C69.22, C69.31-C69.32, C79.89,
D31.21-D31.22 and D31.31-D31.32, up to four (4) extended ophthalmoscopic
examinations may be required per eye, per year.  
  
Other conditions usually require no more than two (2) extended ophthalmoscopic
examinations per eye, per year.  
  
Extended ophthalmoscopy is a physician service (examination of the eye)
commonly occurring during the global post-operative period of ophthalmic
surgery. As a physician service, it is included in the aftercare of the
patient and is not separately billable.  
  
Fundus photography is usually medically necessary no more than two times per
year.  
  
Fundus photography of a normal retina will be considered not medically
necessary.  
  
Services exceeding these parameters will be considered not medically
necessary.  
  
 ** _*ICD-10 list for up to extended 6 ophthalmoscopic examinations_**  
  
  
A18.53, A18.54, E08.311, E08.319, E08.321, E08.329, E08.331, E08.339, E08.341,
E08.349, E08.351, E08.359, E09.311, E09.319, E09.321, E09.329, E09.331,
E09.339, E09.341, E09.349, E09.351, E09.359, E10.311, E10.319, E10.321,
E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.311,
E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351,
E11.359, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341,
E13.349, E13.351, E13.359, G45.3, H16.241, H16.242, H16.243, H20.00, H20.011,
H20.012, H20.013, H20.021, H20.022, H20.023, H20.031, H20.032, H20.033,
H20.41, H20.042, H20.043, H20.11, H20.12, H20.13, H20.21, H20.22, H20.23,
H20.811, H20.812, H20.813, H20.821, H20.822, H20.823, H20.9, H21.01, H21.02,
H21.03, H21.1X1, H21.1X2, H21.1X3, H21.211, H21.212, H21.213, H21.221,
H21.222, H21.223, H21.231, H21.232, H21.233, H21.241, H21.242, H21.423,
H21.251, H21.252, H21.253, H21.261, H21.262, H21.263, H21.271, H21.272,
H21.273, H21.301, H21.302, H21.303, H21.311, H21.312, H21.313, H21.321,
H21.322, H21.323, H21.331, H21.332, H21.333, H21.341, H21.342, H21.343,
H21.351, H21.352, H21.353, H21.41, H21.42, H21.43, H21.501, H21.502, H21.503,
H21.511, H21.512, H21.513, H21.521, H21.522, H21.523, H21.531, H21.532,
H21.533, H21.541, H21.542, H21.543, H21.551, H21.552, H21.553, H21.561,
H21.562, H21.563, H21.81, H21.82, H21.89, H21.9, H22, H30.001, H30.002,
H30.003, H30.011, H30.012, H30.013, H30.021, H30.022, H30.023, H30.031,
H30.032, H30.033, H30.041, H30.042, H30.043, H30.101, H30.102, H30.103,
H30.111, H30.112, H30.113, H30.121, H30.122, H30.123, H30.131, H30.132,
H30.133, H30.141, H30.142, H30.143, H30.21, H30.22, H30.23, H30.811, H30.812,
H30.813, H30.891, H30.892, H30.893, H30.91, H30.92, H30.93, H31.001, H31.002,
H31.003, H31.011, H31.012, H31.013, H31.021, H31.022, H31.023, H31.091,
H31.092, H31.093, H31.101, H31.102, H31.103, H31.111, H31.112, H31.113,
H31.121, H31.122, H31.123, H31.20, H31.21, H31.22, H31.23, H31.301, H31.302,
H31.0303, H31.311, H31.312, H31.313, H31.321, H31.322, H31.323, H31.401,
H31.402, H31.403, H31.411, H31.412, H31.413, H31.421, H31.422, H31.423, H31.8,
H31.9, H32, H33.001, H33.002, H33.003, H33.011, H33.012, H33.013, H33.021,
H33.022, H33.023, H33.031, h33.032. H33.033, H33.041, H33.042, H33.043,
H33.051, H33.052, H33.053, H33.101, H33.102, H33.103, H33.111, H33.112,
H33.113, H33.121, H33.122, H33.123, H33.191, H33.192, H33.193, H33.20, H33.21,
H33.22, H33.23, H33.301, H33.302, H33.303, H33.311, H33.312, H33.313, H33.321,
H33.322, H33.323, H33.331, H33.332, H33.333, H33.41, H33.42, H33.43, H33.8,
H34.01, H34.02, H34.03, H34.11, H34.12, H34.13, H34.211, H34.212, H34.213,
H34.231, H34.232, H34.233, H34.811, H34.812, H34.813, H34.821, H34.822,
H34.823, H34.831, H34.832, H34.833, H34.9, H35.00, H35.011, H35.012, H35.013,
H35.021, H35.022, H35.023, H35.031, H35.032, H35.033, H35.041, H35.042,
H35.043, H35.051, H35.052, H35.053, H35.061, H35.062, H35.063, H35.071,
H35.072, H35.073, H35.09, H35.111, H35.112, H35.113, H35.121, H35.122,
H35.123, H35.131, H35.132, H35.133, H35.141, H35.142, H35.143, H35.151,
H35.152, H35.153, H35.161, H35.162, H35.163, H35.21, H35.22, H35.23, H35.30,
H35.31, H35.32, H35.33, H35.341, H35.342, H35.343, H35.351, H35.352, H35.353,
H35.361, H35.362, H35.363, H35.371, H35.372, H35.373, H35.381, H35.382,
H35.383, H35.40, H35.411, H35.412, H35.413, H35.421, H35.422, H35.423,
H35.431, H35.432, H35.433, H35.441, H35.442, H35.443, H35.451, H35.452,
H35.453, H35.461, H35.462, H35.463, H35.50, H35.51, H35.52, H35.53, H35.54,
H35.61, H35.62, H35.63, H35.70, H35.711, H35.712, H35.713, H35.721, H35.722,
H35.723, H35.731, H35.732, H35.733, H35.81, H35.82, H35.89, H35.9, H36,
H36.811, H36.812, H36.813, H36.821, H36.822, H36.823, H36.89, H40.001,
H40.002, H40.003, H40.011, h40.012, H40.013, H40.031, H40.032, H40.033,
H40.041, H40.042, H40.043, H40.051, H40.052, H40.053, H40.10X1, H40.10X2,
H40.10X3, H40.10X4, H40.11X1, H40.11X2, H40.11X3, H40.11X4, H40.1211,
H40.1213, H40.1214, H40.1221, H40.1222, H40.1223, H40.1224, H40.1231,
H40.1232, H40.1233, H40.1234, H40.1311, H40.1312, H40.1313, H40.1314,
H40.1321, H40.1322, H40.1323, H40.1324, H40.1331, H40.1332, H40.1333,
H40.1334, H40.1411, H40.1412, H40.1413, H40.1414, H40.1421, H40.1422,
H40.1423, H40.1424, H40.1431, H40.1432, H40.1433, H40.1434, H40.151, H40.152,
H40.153, H40.20X1, H40.20X2, H40.20X3, H40.20X4, H40.211, H40.212, H40.213,
H40.2211, H40.2212, H40.2213, H40.2214, H40.2221, H40.2222, H40.2223,
H40.2224, H40.2231, H40.2232, H40.2233, H40.2234, H40.231, H40.232, H40.233,
H40.241, H40.242, H40.243, H40.31X1, H40.31X2, H40.31X3, H40.31X4, H40.32X1,
H40.32X2, H40.32X3, H40.32X4, H40.33X1, H40.33X2, H40.33X3, H40.33X4,
H40.41X1, H40.41X2, H40.41X3, h40.41X4, H40.42X1, H40.42X2, H40.42X3,
H40.42X4, H40.43X1, H40.43X2, H40.43X3, H40.43X4, H40.51X1, H40.51X2,
H40.51X3, H40.51X4, H40.52X1, H40.52X2, H40.52X3, H40.52X4, H40.53X1,
H40.53x2, H40.53X3, H40.53X4, H40.61X1, H40.61X2, H40.61X3, H40.61X4,
H40.62X1, H40.62X2, H40.62X3, H40.62X4, H40.63X1, H40.63X2, H40.63X3,
H40.63X4, H40.811, H40.812, H40.813, H40.821, h40.822, H40.823, H40.831,
H40.832, H40.833, H40.89, H40.9, H42, H44.001, H44.002, H44.003, H44.011,
H44.012, H44.013, H44.021, H44.022, H44.023, H44.111, H44.112, H44.113,
H44.121, H44.122, H44.123, H44.131, H44.132, H44.133, H44.19, H44.21, H44.22,
H44.23, H44.30, H44.311, H44.312, H44.313, H44.321, H44.322, H44.323, H44.391,
H44.392, H44.393, H44.40, H44.411, H44.412, H44.413, H44.422, H44.423,
H44.431, H44.432, H44.433, , H44.441, H44.442, H44.443, H44.50, H44.511,
H44.512, H44.513, H44.521, H44.522, H44.523, H44.531, H44.532, H44.533,
H44.601, H44.602, H44.603, H44.611, H44.612, H44.613, H44.621, H44.622,
H44.623, H44.631, H44.632, H44.633, H44.641, H44.642, H44.643, H44.651,
H44.652, H44.653, H44.691, H44.692, H44.693, H44.701, H44.702, H44.703,
H44.711, H44.712, H44.713, H44.721, H44.722, H44.723, H44.731, H44.732,
H44.733, H44.741, H44.742, H44.743, H44.751, H44.752, H44.753, H44.791,
H44.792, H44.793, H44.811, H44.812, H44.813, H44.821, H44.822, H44.823,
H44.89, H44.9, Q15.0

**Other Comments:**  
  
For claims submitted to the Part A MAC: this coverage determination also
applies within states outside the primary geographic jurisdiction with
facilities that have nominated CGS Administrators, LLC. to process their
claims.  
  
Bill type codes only apply to providers who bill these services to the Part A
MAC. Bill type codes do not apply to physicians, other professionals and
suppliers who bill these services to the carrier or Part B MAC.  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.  
  
For dates of service on or after April 1, 2010, bill type 77X should be used
to report FQHC services.