Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.
From the April 2015 edition of AOA Focus, page 50.
There has been some confusion regarding the appropriate reporting of code 92250, as recommended in the April 1999 issue of the Current Procedural Terminology (CPT®) Assistant newsletter. The Coding Experts would like to clarify whether it is appropriate to report scanning laser ophthalmoscopy technology when it is used to produce fundus photographs.
Prior to 2014, according to CPT Assistant, it was not appropriate to assign CPT code 92250 for scanning laser fundus technology (CPT code 92135). It stated that CPT code 92250, fundus photography with interpretation and report, which describes generation of a retinal image only and no data generation, would be appropriately assigned for this procedure. CPT based its opinion on code 92135 (scanning computerized ophthalmic diagnostic imaging [SCODI], posterior segment, [e.g., scanning laser] with interpretation and report, unilateral) being used to describe a method of objective measurement involving a quantitative determination of the thickness of the retinal nerve fiber. The computer analysis of the measurement data was placed in a database file to allow future comparison of the patient information at follow-up examinations.
As ophthalmic diagnostic imaging technology advanced over the years, two new codes—92133 (SCODI, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) and 92134 (SCODI, posterior segment, with interpretation and report, unilateral or bilateral; retina)—were created in the 2011 CPT code set to replace deleted code 92135.
In 2013, a Medicare Part B contractor further confused the situation by stating that fundus photography uses a special camera to photograph structures behind the lens of the eye, including vitreous, retina, choroid and optic nerve. It specifically stated that this procedure does not include laser scanning of the retina.
But, as of November 2014, CPT Assistant clarified that if the scanner produces an image of the retina or optic nerve along with other data and imaging for quantitative analysis, it would be appropriate to report a single service from the appropriate SCODI range (92133-92134). If only an image is obtained, then code 92250 would be reported, it stated.
It further clarifies that if the only necessary service provided is generating a fundus image without the need to quantify the nerve fiber layer thickness and to analyze the data via a computer, then reporting code 92250 is appropriate, even if the image was taken with a scanning laser.
Just one month later, in December 2014, CPT addressed another component to the use of new technologies using retinal imaging. Specifically, it describes a situation when an ophthalmologic photographer takes fundus autofluorescent images without the need for intravenous fluorescein or indocyanine green dye. The article reports code 92250 would be reported either as part of a series of fundus images or as a stand-alone service. An analogous service provided by a doctor of optometry, obtaining red-free images at the time of color photography, is not coded separately.
To summarize, as stated several times over the past few months, ophthalmic technology is evolving more quickly than CPT can keep up. As these changes in coding guidance arise, we will keep you posted. But in the meantime, always check the carrier's policy to make sure that you are following correctly.
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Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.