Effective Date: October 14, 2019

Last Updated: June 06, 2021

Purpose:

This policy provides guidelines for reimbursement of ocular photography.

Scope:

Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 92285: External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography)

Policy:

External ocular photography is a non-invasive procedure used to photo-document conditions of the external structures of the eye (e.g., eyelids, lashes, sclera, conjunctiva and cornea). When performing photography of an eye segment, Horizon NJ Health limits the procedure to no more than two (2) times in one (1) year.

Procedure:

Horizon NJ Health will not consider for reimbursement ocular photography when billed more than two (2) times in a year.

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding