L31496-LCD

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Local Coverage Determination (LCD) for Fundus Photography (L31496)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L31496

LCD Title

Fundus Photography

Contractor's Determination Number A92250

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/13/2011 Original Determination Ending Date

Revision Effective Date

For services performed on or after 02/13/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the 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, italicized text represent quotation from one or more of the following CMS sources: National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology

Indications and Limitations of Coverage and/or Medical Necessity

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.

First Coast Service Options, Inc. (FCSO) Medicare will cover fundus photography if accompanied by fluorescein dye angiography when used to evaluate abnormalities or degeneration of the macula, the peripheral retina or 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. 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 and are at or above 21mm Hg or there is a difference in cup/disc ratio between the two eyes of 20% or greater.

• Intraocular pressures are less then 22mm Hg and there is clear fundoscopic evidence of glaucomatous optic nerve damage (e.g., abnormal cup size, thinning or notching of the disc rim, progressive change, disc hemorrhage, 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. 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. 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

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).

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.

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 in the table below.

Fundus photography and posterior segment SCODI are frequently used together for the following diagnoses

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.

013x Hospital Outpatient 085x 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 - 115.99 opens in new window

HISTOPLASMOSIS UNSPECIFIED WITHOUT MANIFESTATION - HISTOPLASMOSIS UNSPECIFIED WITH OTHER MANIFESTATION

130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS

190.0 - 190.9 opens in new window

MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - 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 - 239.89 opens in new window

250.50 - 250.53 opens in new window

NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID - NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES

DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

270.2 OTHER DISTURBANCES OF AROMATIC AMINO-ACID METABOLISM 282.60 - 282.69 opens

in new window SICKLE-CELL DISEASE UNSPECIFIED - OTHER SICKLE-CELL DISEASE WITH CRISIS

340 MULTIPLE SCLEROSIS

360.20 - 360.29 opens in new window

360.30 - 360.34 opens

DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED - OTHER DEGENERATIVE DISORDERS OF GLOBE

in new window HYPOTONY OF EYE UNSPECIFIED - FLAT ANTERIOR CHAMBER OF EYE

360.40 - 360.44 opens

in new window DEGENERATED GLOBE OR EYE UNSPECIFIED - LEUCOCORIA

360.50 - 360.59 opens in new window

360.60 - 360.69 opens in new window

FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY MAGNETIC IN OTHER OR MULTIPLE SITES

FOREIGN BODY INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY IN OTHER OR MULTIPLE SITES

360.89 OTHER DISORDERS OF GLOBE

361.00 - 361.9 opens in RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - UNSPECIFIED RETINAL

new window

362.01 - 362.07* opens

DETACH

in new window BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA

362.10 - 362.18 opens

in new window BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS

362.21 - 362.29 opens

in new window RETROLENTAL FIBROPLASIA - OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.30 - 362.37 opens

in new window RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA

362.40 - 362.43 opens in new window

362.50 - 362.57 opens in new window

362.60 - 362.66 opens in new window

362.70 - 362.77 opens in new window

362.81 - 362.89 opens

RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA

PERIPHERAL RETINAL DEGENERATION UNSPECIFIED - SECONDARY VITREORETINAL DEGENERATIONS

HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE

in new window RETINAL HEMORRHAGE - OTHER RETINAL DISORDERS

362.9 UNSPECIFIED RETINAL DISORDER 363.00 - 363.9 opens in

new window FOCAL CHORIORETINITIS UNSPECIFIED - UNSPECIFIED DISORDER OF CHOROID

364.24 VOGT-KOYANAGI SYNDROME

364.3 UNSPECIFIED IRIDOCYCLITIS 365.00 - 365.9 opens in

new window PREGLAUCOMA UNSPECIFIED - UNSPECIFIED GLAUCOMA

368.51 - 368.59 opens in new window

377.00 - 377.04 opens

PROTAN DEFECT - OTHER COLOR VISION DEFICIENCIES

in new window PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME

377.10 - 377.16 opens

in new window OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY

377.21 - 377.24 opens

in new window DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA

377.30 - 377.39 opens

in new window OPTIC NEURITIS UNSPECIFIED - OTHER OPTIC NEURITIS

377.41 - 377.49 opens

in new window ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE

377.51 - 377.54 opens in new window

DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS

379.07 POSTERIOR SCLERITIS

379.11 SCLERAL ECTASIA 379.21 - 379.29 opens

in new window VITREOUS DEGENERATION - 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 - 714.9 opens in

new window RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

743.51 - 743.59 opens in new window

VITREOUS ANOMALIES CONGENITAL - OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT

759.5 TUBEROUS SCLEROSIS

759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED 759.81 - 759.89 opens

in new window PRADER-WILLI SYNDROME - 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 - 950.9 opens in

new window OPTIC NERVE INJURY - 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.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations 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. 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, slides, prints, digital photography, computerized analysis, or 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.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

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

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

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period 10/21/2010

End Date of Comment Period 12/05/2010

Start Date of Notice Period 12/30/2010

Revision History Number Original

Revision History Explanation Revision Number Original Start Date of Comment Period:10/21/2010

Start Date of Notice Period:12/05/2010 Original Effective Date:12/30/2010

LCR A2010-070

December 2010 Bulletin

Reason for Change