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

This article contains coding and other guidelines that complement the local
coverage determination (LCD) for Ophthalmology: Posterior Segment Imaging
(Extended Ophthalmoscopy and Fundus Photography).  
  
**Coding Information:**  
  
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.

**Documentation Requirements:**  
  
 **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.
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. 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 attached Appendix
A of this article 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 (ICD-10-CM codes H40.001-H40.152 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.  
  
 **Appendices:**

See attachment in LCD L33567  
  
 **Utilization Guidelines:**  
  
Patients actively being treated with intravitreal injections of medication for
exudative AMD (ICD-10-CM code ranges H35.3210-H35.3213, H35.3220-H35.3223,
H35.3230- H35.3233) may require up to 12 extended ophthalmoscopies per eye,
per year.  
  
Conditions coded with other ICD-10-CM codes in the ranges A18.53; A18.54;
E08.311-E08.359 Diabetes mellitus due to underlying condition with ophthalmic
complications E09.311-E09.359 Drug or chemical induced diabetes mellitus with
ophthalmic complications;E10.311-E10.359 Type 1 diabetes mellitus with
ophthalmic complications; E11.311-E11.359 Type 2 diabetes mellitus with
ophthalmic complications; E13.311-E13.359 Other specified diabetes mellitus
with ophthalmic complications; H16.241-H16.249 Ophthalmia nodosa;
H20.00-H21.1X1; G45.3 Diseases of the eye and adnexa may require up to six (6)
extended ophthalmoscopic examinations per eye, per year.  
  
For ICD-10-CM codes C69.20-C69.42 Malignant neoplasm of eye and adnexa;
C79.89-C79.9 Secondary malignant neoplasm of other and unspecified sites;
D31.20-D31.32 Benign neoplasm of eye and adnexa 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.