LCD/NCD Portal

L31496

 

FUNDUS PHOTOGRAPHY

 

02/13/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• Medicare will cover fundus photography if accompanied by fluorescein dye angiography when used to evaluate:

o Abnormalities or degeneration of the macula.

o The peripheral retina.

o The posterior pole.

• Fundus photography may be covered as a stand-alone procedure without fluorescein dye angiography following recently performed non-surgical or surgical treatment for macular pathology.

• Preglaucoma, borderline glaucoma and glaucoma are generally slow disease processes which can be followed by modalities other than fundus photography.

o Baseline studies will, however, be allowed when performed by the treating physician as part of initial glaucoma eye care. Either of two situations may apply:

 Intraocular pressures are clearly documented in the patient's medical record.

 Above 21mm Hg.

 There is a difference in cup/disc ratio between the two eyes of 20% or greater.

• Intraocular pressures are less than 22mm Hg and there is clear fundoscopic evidence of glaucomatous optic nerve damage:

o Abnormal cup size.

o Thinning or notching of the disc rim.

o Progressive change.

o Disc hemorrhage.

o Nerve fiber layer defects.

• In either instance, repeat studies by the same physician more than once per year would generally not be expected unless other clinical indications exist to justify the study.

• Fundus photos may be of value in the documentation of rapidly evolving diabetic retinopathy.

o In the absence of prior treatment, studies would not generally be performed for this indication more frequently than every 6 months.

• Fundus photography may be indicated to document abnormalities related to a disease process affecting the eye, or to follow the course of such disease.

Limitations

• Fundus photography is considered medically reasonable and necessary when it is furnished by a qualified optometrist or ophthalmologist in the course of the evaluation and management of a retinal disorder or another condition that has affected the retina as outlined above.

o Therefore, the digital imaging systems for the detection and evaluation of diabetic retinopathy used to acquire retinal images through a dilated pupil with remote interpretation do not meet Medicare’s reasonableness and necessity criteria for fundus photography (CPT codes 92227 and 92228).

• Performing Fundus Photography and SCODI on the Same Day on the Same Eye:

o Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133 or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease.

 However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye.

 In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250 (National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology).

o The physician is not precluded from performing fundus photography and posterior segment SCODI on the same eye on the same day under appropriate circumstances (i.e., when each service is necessary to evaluate and treat the patient.

o FCSO Medicare will consider fundus photography and posterior segment SCODI medically reasonable and necessary when performed on the same eye on the same day as outlined below.

o Fundus photography and posterior segment SCODI are frequently used together for the following ICD-9-CM codes

115.02

190.6

224.6

228.03

360.21

360.30-360.34

361.00-361.07

361.10-361.19

361.2

361.30-361.33

361.81

362.01

362.02

362.03

362.04

362.05

362.06

362.07

362.10-362.18

362.29

362.31

362.32

362.35

362.36

362.37

362.40-362.43

362.50-362.57

362.70-362.77

362.81

362.82

362.83

362.85

363.00-363.08

363.10-363.15

363.20-363.22

363.30-363.35

363.40-363.43

363.54

363.63

363.70-363.72

743.58

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0510 Clinic - General Classification

0920 Other Diagnostic Services - General Classification

 

CPT/HCPCS Codes

 

 

92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT

 

 

ICD-9 Codes that Support Medical Necessity

 

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

115.02 HISTOPLASMA CAPSULATUM RETINITIS

115.90 HISTOPLASMOSIS UNSPECIFIED WITHOUT MANIFESTATION

115.91 HISTOPLASMOSIS MENINGITIS UNSPECIFIED

115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED

115.93 HISTOPLASMOSIS PERICARDITIS UNSPECIFIED

115.94 HISTOPLASMOSIS ENDOCARDITIS

115.95 HISTOPLASMOSIS PNEUMONIA UNSPECIFIED

115.99 HISTOPLASMOSIS UNSPECIFIED WITH OTHER MANIFESTATION

130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT

190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND

190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA

190.4 MALIGNANT NEOPLASM OF CORNEA

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT

190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED

224.5 BENIGN NEOPLASM OF RETINA

224.6 BENIGN NEOPLASM OF CHOROID

228.03 HEMANGIOMA OF RETINA

234.0 CARCINOMA IN SITU OF EYE

238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES

239.81 NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID

239.89 NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.51 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.52 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.53 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

270.2 OTHER DISTURBANCES OF AROMATIC AMINO-ACID METABOLISM

282.60 SICKLE-CELL DISEASE UNSPECIFIED

282.61 HB-SS DISEASE WITHOUT CRISIS

282.62 HB-SS DISEASE WITH CRISIS

282.63 SICKLE-CELL/HB-C DISEASE WITHOUT CRISIS

282.64 SICKLE-CELL/HB C DISEASE WITH CRISIS

282.68 OTHER SICKLE-CELL DISEASE WITHOUT CRISIS

282.69 OTHER SICKLE-CELL DISEASE WITH CRISIS

340 MULTIPLE SCLEROSIS

360.20 DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED

360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA

360.23 SIDEROSIS OF GLOBE

360.24 OTHER METALLOSIS OF GLOBE

360.29 OTHER DEGENERATIVE DISORDERS OF GLOBE

360.30 HYPOTONY OF EYE UNSPECIFIED

360.31 PRIMARY HYPOTONY OF EYE

360.32 OCULAR FISTULA CAUSING HYPOTONY

360.33 HYPOTONY ASSOCIATED WITH OTHER OCULAR DISORDERS

360.34 FLAT ANTERIOR CHAMBER OF EYE

360.40 DEGENERATED GLOBE OR EYE UNSPECIFIED

360.41 BLIND HYPOTENSIVE EYE

360.42 BLIND HYPERTENSIVE EYE

360.43 HEMOPHTHALMOS EXCEPT CURRENT INJURY

360.44 LEUCOCORIA

360.50 FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED

360.51 FOREIGN BODY MAGNETIC IN ANTERIOR CHAMBER OF EYE

360.52 FOREIGN BODY MAGNETIC IN IRIS OR CILIARY BODY

360.53 FOREIGN BODY MAGNETIC IN LENS

360.54 FOREIGN BODY MAGNETIC IN VITREOUS

360.55 FOREIGN BODY MAGNETIC IN POSTERIOR WALL

360.59 INTRAOCULAR FOREIGN BODY MAGNETIC IN OTHER OR MULTIPLE SITES

360.60 FOREIGN BODY INTRAOCULAR UNSPECIFIED

360.61 FOREIGN BODY IN ANTERIOR CHAMBER

360.62 FOREIGN BODY IN IRIS OR CILIARY BODY

360.63 FOREIGN BODY IN LENS

360.64 FOREIGN BODY IN VITREOUS

360.65 FOREIGN BODY IN POSTERIOR WALL OF EYE

360.69 INTRAOCULAR FOREIGN BODY IN OTHER OR MULTIPLE SITES

360.89 OTHER DISORDERS OF GLOBE

361.00 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED

361.01 RECENT RETINAL DETACH PARTIAL WITH SINGLE DEFECT

361.02 RECENT RETINAL DETACH PARTIAL WITH MULTIPLE DEFECTS

361.03 RECENT RETINAL DETACH PARTIAL WITH GIANT TEAR

361.04 RECENT RETINAL DETACH PARTIAL WITH RETINAL DIALYSIS

361.05 RECENT RETINAL DETACH TOTAL OR SUBTOTAL

361.06 OLD RETINAL DETACH PARTIAL

361.07 OLD RETINAL DETACH TOTAL OR SUBTOTAL

361.10 RETINOSCHISIS UNSPECIFIED

361.11 FLAT RETINOSCHISIS

361.12 BULLOUS RETINOSCHISIS

361.13 PRIMARY RETINAL CYSTS

361.14 SECONDARY RETINAL CYSTS

361.19 OTHER RETINOSCHISIS AND RETINAL CYSTS

361.2 SEROUS RETINAL DETACH

361.30 RETINAL DEFECT UNSPECIFIED

361.31 ROUND HOLE OF RETINA WITHOUT DETACH

361.32 HORSESHOE TEAR OF RETINA WITHOUT DETACH

361.33 MULTIPLE DEFECTS OF RETINA WITHOUT DETACH

361.81 TRACTION DETACH OF RETINA

361.89 OTHER FORMS OF RETINAL DETACH

361.9 UNSPECIFIED RETINAL DETACH

362.01 BACKGROUND DIABETIC RETINOPATHY

362.02 PROLIFERATIVE DIABETIC RETINOPATHY

362.03 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS

362.04 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY

362.05 MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.06 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.07* DIABETIC MACULAR EDEMA

362.10 BACKGROUND RETINOPATHY UNSPECIFIED

362.11 HYPERTENSIVE RETINOPATHY

362.12 EXUDATIVE RETINOPATHY

362.13 CHANGES IN VASCULAR APPEARANCE OF RETINA

362.14 RETINAL MICROANEURYSMS NOS

362.15 RETINAL TELANGIECTASIA

362.16 RETINAL NEOVASCULARIZATION NOS

362.17 OTHER INTRARETINAL MICROVASCULAR ABNORMALITIES

362.18 RETINAL VASCULITIS

362.21 RETROLENTAL FIBROPLASIA

362.22 RETINOPATHY OF PREMATURITY, STAGE 0

362.23 RETINOPATHY OF PREMATURITY, STAGE 1

362.24 RETINOPATHY OF PREMATURITY, STAGE 2

362.25 RETINOPATHY OF PREMATURITY, STAGE 3

362.26 RETINOPATHY OF PREMATURITY, STAGE 4

362.27 RETINOPATHY OF PREMATURITY, STAGE 5

362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.30 RETINAL VASCULAR OCCLUSION UNSPECIFIED

362.31 CENTRAL RETINAL ARTERY OCCLUSION

362.32 RETINAL ARTERIAL BRANCH OCCLUSION

362.33 PARTIAL RETINAL ARTERIAL OCCLUSION

362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION

362.35 CENTRAL RETINAL VEIN OCCLUSION

362.36 VENOUS TRIBUTARY (BRANCH) OCCLUSION OF RETINA

362.37 VENOUS ENGORGEMENT OF RETINA

362.40 RETINAL LAYER SEPARATION UNSPECIFIED

362.41 CENTRAL SEROUS RETINOPATHY

362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM

362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.50 MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED

362.51 NONEXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.52 EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.53 CYSTOID MACULAR DEGENERATION OF RETINA

362.54 MACULAR CYST HOLE OR PSEUDOHOLE OF RETINA

362.55 TOXIC MACULOPATHY OF RETINA

362.56 MACULAR PUCKERING OF RETINA

362.57 DRUSEN (DEGENERATIVE) OF RETINA

362.60 PERIPHERAL RETINAL DEGENERATION UNSPECIFIED

362.61 PAVING STONE DEGENERATION OF RETINA

362.62 MICROCYSTOID DEGENERATION OF RETINA

362.63 LATTICE DEGENERATION OF RETINA

362.64 SENILE RETICULAR DEGENERATION OF RETINA

362.65 SECONDARY PIGMENTARY DEGENERATION OF RETINA

362.66 SECONDARY VITREORETINAL DEGENERATIONS

362.70 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED

362.71 RETINAL DYSTROPHY IN SYSTEMIC OR CEREBRORETINAL LIPIDOSES

362.72 RETINAL DYSTROPHY IN OTHER SYSTEMIC DISORDERS AND SYNDROMES

362.73 VITREORETINAL DYSTROPHIES

362.74 PIGMENTARY RETINAL DYSTROPHY

362.75 OTHER DYSTROPHIES PRIMARILY INVOLVING THE SENSORY RETINA

362.76 DYSTROPHIES PRIMARILY INVOLVING THE RETINAL PIGMENT EPITHELIUM

362.77 RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE

362.81 RETINAL HEMORRHAGE

362.82 RETINAL EXUDATES AND DEPOSITS

362.83 RETINAL EDEMA

362.84 RETINAL ISCHEMIA

362.85 RETINAL NERVE FIBER BUNDLE DEFECTS

362.89 OTHER RETINAL DISORDERS

362.9 UNSPECIFIED RETINAL DISORDER

363.00 FOCAL CHORIORETINITIS UNSPECIFIED

363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY

363.03 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE

363.04 FOCAL CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.05 FOCAL RETINITIS AND RETINOCHOROIDITIS JUXTAPAPILLARY

363.06 FOCAL RETINITIS AND RETINOCHOROIDITIS MACULAR OR PARAMACULAR

363.07 FOCAL RETINITIS AND RETINOCHOROIDITIS OF OTHER POSTERIOR POLE

363.08 FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

363.10 DISSEMINATED CHORIORETINITIS UNSPECIFIED

363.11 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS POSTERIOR POLE

363.12 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.13 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS GENERALIZED

363.14 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS METASTATIC

363.15 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 CHORIORETINITIS UNSPECIFIED

363.21 PARS PLANITIS

363.22 HARADA'S DISEASE

363.30 CHORIORETINAL SCAR UNSPECIFIED

363.31 SOLAR RETINOPATHY

363.32 OTHER MACULAR SCARS OF RETINA

363.33 OTHER SCARS OF POSTERIOR POLE OF RETINA

363.34 PERIPHERAL SCARS OF RETINA

363.35 DISSEMINATED SCARS OF RETINA

363.40 CHOROIDAL DEGENERATION UNSPECIFIED

363.41 SENILE ATROPHY OF CHOROID

363.42 DIFFUSE SECONDARY ATROPHY OF CHOROID

363.43 ANGIOID STREAKS OF CHOROID

363.50 HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED

363.51 CIRCUMPAPILLARY DYSTROPHY OF CHOROID PARTIAL

363.52 CIRCUMPAPILLARY DYSTROPHY OF CHOROID TOTAL

363.53 CENTRAL DYSTROPHY OF CHOROID PARTIAL

363.54 CENTRAL CHOROIDAL ATROPHY TOTAL

363.55 CHOROIDEREMIA

363.56 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID PARTIAL

363.57 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL

363.61 CHOROIDAL HEMORRHAGE UNSPECIFIED

363.62 EXPULSIVE CHOROIDAL HEMORRHAGE

363.63 CHOROIDAL RUPTURE

363.70 CHOROIDAL DETACH UNSPECIFIED

363.71 SEROUS CHOROIDAL DETACH

363.72 HEMORRHAGIC CHOROIDAL DETACH

363.8 OTHER DISORDERS OF CHOROID

363.9 UNSPECIFIED DISORDER OF CHOROID

364.24 VOGT-KOYANAGI SYNDROME

364.3 UNSPECIFIED IRIDOCYCLITIS

365.00 PREGLAUCOMA UNSPECIFIED

365.01 OPEN ANGLE WITH BORDERLINE GLAUCOMA FINDINGS

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.03 STEROID RESPONDERS BORDERLINE GLAUCOMA

365.04 OCULAR HYPERTENSION

365.10 OPEN-ANGLE GLAUCOMA UNSPECIFIED

365.11 PRIMARY OPEN ANGLE GLAUCOMA

365.12 LOW TENSION OPEN-ANGLE GLAUCOMA

365.13 PIGMENTARY OPEN-ANGLE GLAUCOMA

365.14 GLAUCOMA OF CHILDHOOD

365.15 RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA

365.22 ACUTE ANGLE-CLOSURE GLAUCOMA

365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA

365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA

365.31 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE

365.32 CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES

365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS

365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT ANOMALIES

365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 PHACOLYTIC GLAUCOMA

365.52 PSEUDOEXFOLIATION GLAUCOMA

365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER

365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK

365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS

365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE

365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS

365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA

365.81 HYPERSECRETION GLAUCOMA

365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE

365.83 AQUEOUS MISDIRECTION

365.89 OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA

368.51 PROTAN DEFECT

368.52 DEUTAN DEFECT

368.53 TRITAN DEFECT

368.54 ACHROMATOPSIA

368.55 ACQUIRED COLOR VISION DEFICIENCIES

368.59 OTHER COLOR VISION DEFICIENCIES

377.00 PAPILLEDEMA UNSPECIFIED

377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE

377.02 PAPILLEDEMA ASSOCIATED WITH DECREASED OCULAR PRESSURE

377.03 PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER

377.04 FOSTER-KENNEDY SYNDROME

377.10 OPTIC ATROPHY UNSPECIFIED

377.11 PRIMARY OPTIC ATROPHY

377.12 POSTINFLAMMATORY OPTIC ATROPHY

377.13 OPTIC ATROPHY ASSOCIATED WITH RETINAL DYSTROPHIES

377.14 GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC

377.15 PARTIAL OPTIC ATROPHY

377.16 HEREDITARY OPTIC ATROPHY

377.21 DRUSEN OF OPTIC DISC

377.22 CRATER-LIKE HOLES OF OPTIC DISC

377.23 COLOBOMA OF OPTIC DISC

377.24 PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.31 OPTIC PAPILLITIS

377.32 RETROBULBAR NEURITIS (ACUTE)

377.33 NUTRITIONAL OPTIC NEUROPATHY

377.34 TOXIC OPTIC NEUROPATHY

377.39 OTHER OPTIC NEURITIS

377.41 ISCHEMIC OPTIC NEUROPATHY

377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS

377.43 OPTIC NERVE HYPOPLASIA

377.49 OTHER DISORDERS OF OPTIC NERVE

377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS

377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS

377.53 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS

377.54 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS

379.07 POSTERIOR SCLERITIS

379.11 SCLERAL ECTASIA

379.21 VITREOUS DEGENERATION

379.22 CRYSTALLINE DEPOSITS IN VITREOUS

379.23 VITREOUS HEMORRHAGE

379.24 OTHER VITREOUS OPACITIES

379.25 VITREOUS MEMBRANES AND STRANDS

379.26 VITREOUS PROLAPSE

379.29 OTHER DISORDERS OF VITREOUS

379.32 SUBLUXATION OF LENS

379.34 POSTERIOR DISLOCATION OF LENS

695.4 LUPUS ERYTHEMATOSUS

710.0 SYSTEMIC LUPUS ERYTHEMATOSUS

714.0 RHEUMATOID ARTHRITIS

714.1 FELTY'S SYNDROME

714.2 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.32 PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.33 MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.4 CHRONIC POSTRHEUMATIC ARTHROPATHY

714.81 RHEUMATOID LUNG

714.89 OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

743.51 VITREOUS ANOMALIES CONGENITAL

743.52 FUNDUS COLOBOMA

743.53 CHORIORETINAL DEGENERATION CONGENITAL

743.54 CONGENITAL FOLDS AND CYSTS OF POSTERIOR SEGMENT

743.55 CONGENITAL MACULAR CHANGES

743.56 OTHER RETINAL CHANGES CONGENITAL

743.57 SPECIFIED CONGENITAL ANOMALIES OF OPTIC DISC

743.58 VASCULAR ANOMALIES CONGENITAL

743.59 OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT

759.5 TUBEROUS SCLEROSIS

759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED

759.81 PRADER-WILLI SYNDROME

759.82 MARFAN SYNDROME

759.83 FRAGILE X SYNDROME

759.89 OTHER SPECIFIED CONGENITAL ANOMALIES

771.0 CONGENITAL RUBELLA

871.5 PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY

871.6 PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY

950.0 OPTIC NERVE INJURY

950.1 INJURY TO OPTIC CHIASM

950.2 INJURY TO OPTIC PATHWAYS

950.3 INJURY TO VISUAL CORTEX

950.9 INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS

961.4 POISONING BY ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA

* ICD-9-CM code 362.07 requires a dual diagnosis. When using ICD-9-CM code 362.07 (diabetic macular edema) a code for diabetic retinopathy (362.01-362.06) must also be used.

 

 

Documentation Requirements

• Medical record documentation maintained by the performing physician must indicate the medical necessity of the fundus photography and be available to Medicare upon request.

o Office records/progress notes must document the complaint, symptomatology, or reason necessitating the test and must include the examination results/findings.

• Photo documentation may be one of the following types: reproducible,

o Slides.

o Prints.

o Digital photography.

o Computerized analysis.

o Stereo photos.

• Medical record documentation must clearly indicate rationale which supports the medical necessity for performing fundus photography and posterior segment SCODI on the same day on the same eye.

• Documentation should also reflect how the test results were used in the patient’s plan of care.

• It would not be considered medically reasonable and necessary to perform fundus photography and posterior segment SCODI on the same day on the same eye to provide additional confirmatory information for a diagnosis or treatment which has already been determined.

 

 

Treatment Logic

• Fundus photography is a procedure involving the use of a retinal camera to photograph the regions of the vitreous, retina, choroid and optic nerve for diagnostic purposes.

• These photographs are also used for therapeutic assessment of recently performed retinal laser surgery and to aid in the interpretation of fluorescein angiography.

 

Sources of Information and Basis for Decision

 

American Academy of Ophthalmology Preferred Practice Patterns for Age-Related Macular Degeneration, Diabetic Retinopathy, and Primary Open-Angle Glaucoma.

 

Ciardella, A., Borodoker, N., Costa, D., Huang, S., Cunningham, Jr., E., Slakter, J. (2002). Imaging the posterior segment in uveitis. Ophthalmology Clinics of North America, 15(3). Retrieved November 7, 2003, from mdconsult database (303398).

 

Duane’s Clinical Ophthalmology

 

FCSO LCD 29179, Fundus Photography, 02/13/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Friedman, D. (2001). Neuro-Ophthalmology. Ophthalmology Clinics of North America, 14(1). Retrieved November 3, 2003, from mdconsult database (276461).

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L31496 Fundus Photography