Ophthalmology Services

Effective Date: August 1, 2021

Purpose:

This policy provides reimbursement guidelines for the billing and reimbursement of ocular screening, fundus photography and extended ophthalmoscopy.

Scope:

Products included:

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

Definitions:

  • CPT Code 92201: Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.
  • CPT Code 92202: Ophthalmoscopy, extended; with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.
  • CPT Code 92227: Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral.
  • CPT Code 92228: Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral.
  • CPT Code 92250: Fundus photography with interpretation and report.
  • CPT Code 99174: Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report
  • CPT Code 99177: Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis

Policy:

Fundus Photography and Extended Ophthalmoscopy

Fundus photography and extended ophthalmoscopy are not routinely part of the comprehensive clinical evaluation of the eye.¹ However, when billed by an eligible provider the following reimbursement rules shall apply.

Horizon NJ Health shall consider for reimbursement fundus photography (CPT codes 92250, 92227-92228) and extended ophthalmoscopy (CPT codes 92201-92202) services for eligible members only when all of the following criteria are met:

  • Fundus photography or extended ophthalmoscopy has an appropriate diagnosis code on the claim to validate the indication for the procedure. Examples of appropriate diagnostic codes include, but are not limited to, macular degeneration, diabetic retinopathy, and malignancy/ocular tumors.²
  • Extended ophthalmoscopy does not occur in the global post-operative period of the eye.
  • Fundus photography or extended ophthalmoscopy is performed by an ophthalmologist or an optometrist.
  • CPT codes 92201 or 92202 are not billed with 92250 on the same date of service. CPT codes 92201 and 92202 are not billed on the same date of service.³

Additionally, fundus photography and extended ophthalmoscopy services are not eligible for reimbursement more than two times, for the same member, during any 12-month period, with the following exceptions;

  • Extended ophthalmoscopy shall be allowed up to 12 times every 12 months when billed with diagnostic codes H35.3210-H35.3213; H35.3220-H35.3223; H35.3230-H35.3233.
  • Extended ophthalmoscopy shall be allowed up to six times every 12 months when billed with diagnostic codes A18.53; A18.54; E08.311-E08.359; E09.311-E09.359; E11.311-E11.359; E13.311-E13.359; H16.241-H16.249; H20.00-H21.1X1; G45.3.
  • Extended ophthalmoscopy shall be allowed up to four times every 12 months when billed with diagnostic codes C69.20-C69.42; C79.89-C79.9; D31.20-D31.32.

There is no need to ap­pend modifiers –RT, –LT, –50, or –52. Submit either 92250, 92227, 92228, 92201 or 92202 without a modifier.⁴

Finally, fundus photography and extended ophthalmoscopy services are not eligible for reimbursement unless all of the following documentation requirements are satisfied:

Fundus Photography (CPT Codes 92250, 92227-92228) Documentation Requirements:

  • Documentation must support the medical necessity and include a detailed history, physical examination and relevant diagnostic testing.
  • The fundus photograph should be part of the permanent medical record. An interpretation and report of the test must also be included, in addition to the photographs themselves. Documentation must also indicate if pupil dilation was performed and which drug was used if applicable.

Extended Ophthalmoscopy (CPT codes 92201-92202) Documentation Requirements:

  • Documentation must support the medical necessity and include a detailed history, physical examination and relevant diagnostic testing.
  • The retinal drawings must be part of the permanent medical record. Documentation must also indicate if pupil dilation was performed and which drug was used if applicable. The retinal drawing must include all of the following:
    • Detailed sketch of the fundus with landmarks and anatomical structures labeled and identified
      • Abnormalities of the optic nerve in a separate drawing (if applicable)
      • Drawings must be clearly labeled and/or highlighted with four (4) to six (6) standard colors or non-colored drawings that are clearly labeled
      • If the patient has a diagnosis of glaucoma, the drawing must also include the optic nerve, any noted pathology around the optic nerve and the method of examination (i.e., Scleral depression, CPT code 92201)

Instrument-based ocular screening

Instrument-based ocular screening can be used to detect amblyogenic refractive errors in young children.⁵

Horizon NJ Health shall consider for reimbursement instrument-based ocular screening (CPT codes 99174 and 99177) in children 4 years of age and younger.

Procedure:

Horizon NJ Health will not consider for reimbursement claims submitted for fundus photography and extended ophthalmoscopy when an appropriate diagnosis code is not submitted.

Horizon NJ Health will not consider for reimbursement claims submitted for fundus photography and extended ophthalmoscopy in excess of two times during any 12-month period for the same member, with the following exceptions;

  • Horizon NJ Health will not consider for reimbursement claims submitted for extended ophthalmoscopy over twelve (12) times every twelve (12) months when billed with diagnostic codes H35.3210-H35.3213; H35.3220-H35.3223; H35.3230-H35.3233.
  • Horizon NJ Health will not consider for reimbursement claims submitted for extended ophthalmoscopy over six (6) times every twelve (12) months when billed with diagnostic codes A18.53; A18.54; E08.311-E08.359; E09.311-E09.359; E11.311-E11.359; E13.311-E13.359; H16.241-H16.249; H20.00-H21.1X1; G45.3.
  • Horizon NJ Health will not consider for reimbursement claims submitted for extended ophthalmoscopy over four (4) times every twelve (12) months when billed with diagnostic codes C69.20-C69.42; C79.89-C79.9; D31.20-D31.32.

Horizon NJ Health will not consider for reimbursement claims for fundus photography and extended ophthalmoscopy that are submitted from specialties other than ophthalmology and optometry.

Horizon NJ Health will not consider for reimbursement claims for fundus photography and extended ophthalmoscopy that do not meet the documentation requirements outlined in this policy.

Horizon NJ Health will not consider for reimbursement claims submitted for instrument-based ocular screening in members five (5) years of age and older.

Resources:

  1. American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; Published Online July, 2015. http://one.aao.org/CE/PracticeGuidelines
  2. CMS, National Coverage Determination (NCD) for Intraocular Photography (80.6) https://www.cms.gov/medicare-coverage-database
  3. CMS, National Correct Coding Initiative Edits https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
  4. American Academy of Ophthalmology, Published Online February, 2020. https://www.aao.org/eyenet/article/meet-the-new-codes-for-extended-ophthalmoscopy
  5. Pediatrics November 2012, 130 (5) 983-986; DOI:
    https://doi.org/10.1542/peds.2012-2548
    https://pediatrics.aappublications.org/content/130/5/983.short#sec-4
  6. American Medical Association, Current Procedural Terminology (CPT®) 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.⁶

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.