Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-04,Medicare Claims Manual, chapter 12:40.1.A. Global surgery periodArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL34399-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 OphthalmoscopyCodes 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 initialexam 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 PhotographyCPT 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 GuidelinesAn 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 RequirementsThe patients 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 historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Fundus photographyThe 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 ophthalmoscopyThe 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 patients 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