It’s time for another WTF column. (Keep in mind that WTF stands for “What’re The Facts?”) This time, the facts focus on some recent buzz about fundus photography (CPT code 92250).

A recent webinar on diabetic screening indicated that the Centers for Medicare & Medicaid Services (CMS) and the American Academy of Ophthalmology had formal positions regarding the use of specific instrumentation to qualify an image as a fundus photograph.

Unfortunately, for many who attended the webinar, the information was misleading and led to a significant amount of confusion about which instruments could or could not be used for a fundus photograph.

So, what’re the facts?

No CMS Policy
According to my research, CMS does not currently have any national policy regarding specific instrumentation that can be used as a fundus camera. Remember that the Current Procedural Terminology (CPT), developed by the American Medical Association, defines a procedure and then CMS develops coverage rules and reimbursements based on that definition.
CPT defines code 92250 as: “Fundus photography with interpretation and report.”_¹ It doesn’t specify if it is stereo or not, if it has to be recorded on film or digitally, and so forth.

However, one CMS carrier—Palmetto GBA (not CMS, as represented in the webinar) whose geographical jurisdiction includes Virginia, West Virginia, North Carolina and South Carolina—does have a local coverage determination that states: “Fundus photography uses a special camera to photograph structures behind the lens of the eye, including vitreous, retina, choroids and optic nerve. This procedure does not include laser scanning of the retina.”_²

The presenters of the webinar apparently interpreted this to mean that any instrument that uses a laser would not qualify as a fundus camera, therefore an image created by a laser would not qualify as a fundus photograph. In my opinion, the intent of this carrier’s language was to prevent incidental images produced by an OCT instrument from being billed as a fundus photograph—not to dictate which type of instrumentation must be used for fundus photography.

Subsequently, the carrier has been asked to clarify its policy and provide additional guidance.

No AAO Position
The second statement and reference contained within the webinar was an implication that the American Academy of Ophthalmology had taken a formal stance as an organization on this specific fundus photography issue. In checking the reference provided in the webinar, that is not the case.

The actual reference was an article written by an AAO Coding Executive that stated “The Optos Optomap is image-assisted ophthalmoscopy for evaluation of ocular health. It does not meet the criteria for the CPT code for fundus photography (92250) or the codes for OCT of the posterior segment (92133 for the optic nerve; 92134 for the retina). If you rely on the Optos technique, rather than dilating the patient, then you must bill a lower level eye code or E&M exam. The Optos can be used for a non-covered screening exam, in which case the patient is responsible for payment.”_³

Again, in my opinion, this is not news. The basic Optos has never been advocated for use with CPT code 92250 or as a replacement for dilation. Rather, it has been used as a screening device and with the code S9986 (not medically necessary services). It is always paid for by the patient regardless of any pathology discovered, and should not be converted into a billable (carrier-responsible) procedure based on findings.

Be aware that the Optos devices, as well as other manufacturers’ devices, have the capability to do more than one type of test. Any secondary (medical) test must meet the requirement of medical necessity, must be ordered by the physician, must produce additional information that wasn’t available in the screening image, and requires an interpretation and report to be billable to a medical carrier.

Although Optos was singled out in the Academy publication, this requirement applies to all devices that provide both screening and non-screening services. There are numerous instruments, in addition to Optos, that capture retinal images (not OCT) that use “scanning laser technology” for image acquisition, and thousands of optometrists and ophthalmologists have been properly billing for and being reimbursed for 92250 with them. Nowhere within this referenced article did the American Academy of Ophthalmology state that “use of pseudo-photography does not meet the requirements for the billing of 92250” as represented in the webinar. (In fact, neither CMS nor the AAO refer to the term “pseudo-photography” as referenced in the webinar.)

Technology is developing at an accelerating rate in our profession. Rules and regulations should always be vetted by the practicing physician before using any technology in practice. Keep in mind that rules are geographically specific and that you, not the salesperson or anyone else, is responsible for knowing and following them.

I’m sure that this is not the last statement on this currently controversial topic, but for the time being, I needed (and so did you) to know WTF.

Please send your questions and comments to CodingAbstract@gmail.com.

1. CPT 2014 Professional Edition. Chicago, IL: American Medical Association. 2013: 538.
2. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32953&ContrId=233&ver=8&ContrVer=1&CntrctrSelected=233*1&Cntrctr=233&name=Palmetto+GBA+(11502%2c+MAC+-+Part+B)&DocType=Active&LCntrctr=233*1&bc=AgACAAIAAAAAAA%3d%3d&. Accessed April 3, 2014.
3. Vicchrilli S. Testing Services, Part One: Selecting the CPT Code. EyeNet. 2012 May: 61. Available at: www.aao.org/publications/eyenet/201205/upload/Coding-for-Testing-Services-Part-One-CPT-Codes-PDF.pdf. Accessed April 14, 2014.