Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726)

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 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 photographyThe 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 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. 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 patients 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 L33567Utilization 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.