Procedure Description
92250 Eye exam with photos – Average fee payment $ 82
Fundus photography requires a camera using film or digital media to photograph structures behind the lens of the eye. Near photo-quality images are also obtainable utilizing scanning laser equipment with specialized software. (See the “CPT/HCPCS” section of this LCD and the “Coding Guidelines” section of the LCD Article for coding instructions.)
In order to document a disease process, plan its treatment or follow the progress of a disease, fundus photographs may be necessary. Fundus photographs are not medically necessary simply to document the existence of a condition. However, photographs may be medically necessary to establish a baseline to judge later whether a disease is progressive. Examples are as follows:
- It does not add to the patient’s care to photograph dry age-related maculopathy to document its existence.
- Fundus photography may be necessary to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy. In four to six months, the baseline photograph can be compared to the clinical appearance of the current diabetic retinal edema to see if it is progressing to clinically significant diabetic macular edema. This information can be used to decide whether or not to advise the patient to undergo focal laser photocoagulation.
The intent of these examples is to point out how in the former there is not a therapeutic decision being made, while in the latter there is. The fundus photography should aid in making a clinical decision.
Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
Fundus photography is not a covered service when used to document the absence of pathology (i.e., a normal or healthy fundus or screening) or when the physician elects to incorporate it as a routine procedure. Routine fundus photography for purposes other than documentation, monitoring and treatment of a pathological process falls outside the standard of care as a medical necessity and is thereby not a covered service.
Some organizations recommend that diabetics have an annual dilated eye examination to look for retinal disease; fundus photographs are not an acceptable substitute for the dilated eye exam.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative
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.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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.
CPT/HCPCS Codes
92250© | Eye exam with photos – Fee schedule amount – $77.19 |
Note: Use 92250 only to report photographs obtained with a camera on film or digital media. | |
92499 | Unlisted ophthalmological service or procedure – |
Note: Use 92499 to identify fundus images obtained with scanning laser equipment. |
Billing and Coding Guidelines
The below CPT codes would be bundled if submitted with CPT 92250, avoid that submit with Modifier 92227 and 99211
It should be noted that there are National Correct Coding Initiative (NCCI) mutually exclusive edits for CPT codes 92135 and 92250. A modifier is allowed if performed on separate eyes. However, CPT code 92250 has a bilateral indicator of “2’ on the Medicare Physician Fee Schedule Database. Therefore, the fee schedule amount represents photography of both eyes. Modifier ‐52 should be appended if only one eye is photographed.
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).
Intraocular Photography (also known as Fundus Photography)
a. Intraocular Photography to Diagnose Conditions listed below (CPT code 92250) Intraocular photography when used by an ophthalmologist is covered for the diagnosis of
such conditions as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, or to identify glaucoma, multiple sclerosis and other central nervous system abnormalities.
Applicable service codes: 92250
CPT Code 92250 is a bilateral procedure and should be billed only once.
ICD-10 Diagnoses codes: H52.00, H52.01, H52.02, H52.03, H52.10, H52.11, H52.12, H52.13, H52.201, H52.202, H52.203, H52.209, H52.211, H52.212, H52.213, H52.219, H52.221, H52.222, H52.223, H52.229, H52.31, H52.32, H52.4, H52.511, H52.512, H52.513, H52.519, H52.521, H52.522, H52.523,H52.529, H52.531, H52.532, H52.533, H52.539, H52.6, H52.7, Z83.3, Z83.511, Z83.518, Z01.00, Z01.01
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 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-distinct procedural service or HCPCS modifier XU-unusual, non-overlapping service 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 circ*mstances (i.e., when each service is necessary to evaluate and treat the patient.
ICD-10 Codes that Support Medical Necessity
B20 Human immunodeficiency virus [HIV] disease
B39.4 Histoplasmosis capsulati, unspecified
B39.9 Histoplasmosis, unspecified
B58.01 Toxoplasma chorioretinitis
C69.00 Malignant neoplasm of unspecified conjunctiva
C69.01 Malignant neoplasm of right conjunctiva
C69.02 Malignant neoplasm of left conjunctiva
C69.10 Malignant neoplasm of unspecified cornea
C69.11 Malignant neoplasm of right cornea
C69.12 Malignant neoplasm of left cornea
C69.20 Malignant neoplasm of unspecified retina
C69.21 Malignant neoplasm of right retina
C69.22 Malignant neoplasm of left retina
C69.30 Malignant neoplasm of unspecified choroid
C69.31 Malignant neoplasm of right choroid
C69.32 Malignant neoplasm of left choroid
C69.40 Malignant neoplasm of unspecified ciliary body
C69.41 Malignant neoplasm of right ciliary body
C69.42 Malignant neoplasm of left ciliary body
C69.50 Malignant neoplasm of unspecified lacrimal gland and duct
C69.51 Malignant neoplasm of right lacrimal gland and duct
C69.52 Malignant neoplasm of left lacrimal gland and duct
C69.60 Malignant neoplasm of unspecified orbit
C69.61 Malignant neoplasm of right orbit
C69.62 Malignant neoplasm of left orbit
C69.80 Malignant neoplasm of overlapping sites of unspecified eye and adnexa
C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa
C69.90 Malignant neoplasm of unspecified site of unspecified eye
C69.91 Malignant neoplasm of unspecified site of right eye
C69.92 Malignant neoplasm of unspecified site of left eye
D09.20 Carcinoma in situ of unspecified eye
D09.21 Carcinoma in situ of right eye
D09.22 Carcinoma in situ of left eye
D18.09 Hemangioma of other sites
D31.20 Benign neoplasm of unspecified retina
D31.21 Benign neoplasm of right retina
D31.22 Benign neoplasm of left retina
D31.30 Benign neoplasm of unspecified choroid
D31.31 Benign neoplasm of right choroid
D31.32 Benign neoplasm of left choroid
D48.7 Neoplasm of uncertain behavior of other specified sites
D49.81 Neoplasm of unspecified behavior of retina and choroid
D49.89 Neoplasm of unspecified behavior of other specified sites
D57.00 Hb-SS disease with crisis, unspecified
D57.01 Hb-SS disease with acute chest syndrome
D57.02 Hb-SS disease with splenic sequestration
D57.1 Sickle-cell disease without crisis
D57.20 Sickle-cell/Hb-C disease without crisis
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.219 Sickle-cell/Hb-C disease with crisis, unspecified
D57.80 Other sickle-cell disorders without crisis
D57.811 Other sickle-cell disorders with acute chest syndrome
D57.812 Other sickle-cell disorders with splenic sequestration
D57.819 Other sickle-cell disorders with crisis, unspecified
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 92250 and 92499 (when used to identify fundus images obtained with scanning laser equipment):
Covered for:
017.30–017.36 | Tuberculosis of eye |
042 | Human immunodeficiency virus (hiv) disease |
078.5 | Cytomegaloviral disease |
091.51 | Syphilitic chorioretinitis (secondary) |
094.83 | Syphilitic disseminated retinochoroiditis |
115.02 | Histoplasma capsulatum retinitis |
115.92 | Histoplasmosis, unspecified, retinitis |
130.0 | Meningoencephalitis due to toxoplasmosis |
130.2 | Chorioretinitis due to toxoplasmosis |
130.9 | Toxoplasmosis unspecified |
190.5–190.6 | Malignant neoplasm of eye |
198.4 | Secondary malignant neoplasm of other parts of nervous system |
224.0 | Benign neoplasm of eyeball except conjunctiva cornea retina and choroid |
224.5–224.6 | Benign neoplasm of eye |
225.1 | Benign neoplasm of cranial nerves |
238.8–238.9 | Neoplasm of uncertain behavior of other and unspecified sites and tissues |
250.50–250.51 | Diabetes with ophthalmic manifestations |
264.7 | Other ocular manifestations of vitamin a deficiency |
270.2 | Disorders of amino acid transport and metabolism; other disturbances of aromatic amino acid metabolism |
340 | Multiple sclerosis |
348.2 | Benign intracranial hypertension |
360.00–360.04 | Purulent endophthalmitis |
360.11–360.14 | Other endophthalmitis |
360.19 | Other endophthalmitis |
360.20–360.24 | Degenerative disorders of the globe |
360.30–360.33 | Hypotony of eye |
360.43–360.44 | Degenerated conditions of the globe |
360.50 | Disorders of the globe; foreign body, magnetic, intraocular, unspecified |
360.54–360.55 | Retained (old) intraocular foreign body, magnetic |
360.59 | Disorders of the globe; intraocular foreign body, magnetic, in other or multiple sites |
360.64–360.65 | Retained (old) intraocular foreign body, nonmagnetic |
360.69 | Disorders of the globe; non-magnetic, foreign body in other or multiple sites |
361.00–361.07 | Retinal detachment with retinal defect |
361.10–361.14 | Retinoschisis and retinal cysts |
361.19 | Other retinoschisis and retinal cysts |
361.2 | Retinal detachments and defects; serous retinal detachment |
361.30–361.33 | Retinal defects without detachment |
361.81 | Traction detachment of retina |
361.89 | Other forms of retinal detachment |
361.9 | Unspecified retinal detachment |
362.01–362.07 | Diabetic retinopathy |
362.10–362.18 | Other background retinopathy and retinal vascular changes |
362.20–362.27 | Other proliferative retinopathy |
362.29 | Other non-diabetic proliferative retinopathy |
362.30–362.37 | Retinal vascular occlusion |
362.40–362.43 | Separation of retinal layers |
362.50–362.57 | Degeneration of macula and posterior pole |
362.60–362.66 | Peripheral retinal degenerations |
362.70–362.77 | Hereditary retinal dystrophies |
362.81–362.85 | Other retinal disorders |
362.89 | Other retinal disorders |
362.9 | Other retinal disorders; unspecified retinal disorder |
363.00–363.01 | Focal chorioretinitis and focal retinochoroiditis |
363.03–363.08 | Focal chorioretinitis and focal retinochoroiditis |
363.10–363.15 | Disseminated chorioretinitis and disseminated retinochoroiditis |
363.20–363.22 | Other and unspecified forms of chorioretinitis and retinochoroiditis |
363.30–363.35 | Chorioretinal scars |
363.40–363.43 | Choroidal degenerations |
363.50–363.57 | Hereditary choroidal dystrophies |
363.61–363.63 | Choroidal hemorrhage and rupture |
363.70–363.72 | Choroidal detachment |
363.8–363.9 | Other disorders of choroid |
365.00–365.04 | Borderline glaucoma [glaucoma suspect] |
365.10–365.15 | Open angle glaucoma |
365.20–365.24 | Primary angle-closure glaucoma |
365.31–365.32 | Corticosteroid-induced glaucoma |
365.41–365.44 | Glaucoma associated with congenital anomalies, dystrophies and systemic syndromes |
365.51–365.52 | Glaucoma associated with disorders of the lens |
365.59 | Glaucoma associated with other lens disorders |
365.60–365.65 | Glaucoma associated with other ocular disorders |
365.81–365.83 | Other specified forms of glaucoma |
365.89 | Other specified forms of glaucoma |
365.9 | Glaucoma, unspecified |
368.54 | Achromatopsia |
368.61 | Congenital night blindness |
377.00–377.04 | Disorders of optic nerve and visual pathways; papilledema |
377.10–377.16 | Disorders of optic nerve and visual pathways; optic atrophy |
377.21–377.24 | Disorders of optic nerve and visual pathways; other disorders of optic disc |
377.30–377.34 | Disorders of optic nerve and visual pathways; optic neuritis |
377.39 | Disorders of optic nerve and visual pathways; other optic neuritis |
377.41–377.43 | Disorders of optic nerve and visual pathways; other disorders of optic nerve |
377.49 | Disorders of optic nerve and visual pathways; other disorders of optic nerve |
379.00 | Other disorders of eye; scleritis, unspecified |
379.07 | Other disorders of eye; posterior scleritis |
379.09 | Other disorders of eye; other scleritis and episcleritis |
379.11 | Scleral ectasia |
379.21–379.26 | Disorders of vitreous body |
379.29 | Other disorders of vitreous |
379.60–379.63 | Inflammation (infection) of postprocedural bleb |
710.0 | Systemic lupus erythematosus |
743.51–743.59 | Congenital cataract and lens anomalies |
759.5–759.6 | Other and unspecified congenital anomalies |
759.82 | Marfan syndrome |
771.0 | Congenital rubella |
871.5–871.6 | Open wound of eyeball |
950.0–950.1 | Injury to optic nerve and pathways |
V10.84 | Personal history of malignant neoplasm of eye |
V58.63 | Long-term (current) use of antiplatelets/antithrombotics |
V58.64 | Long-term (current) use of nonsteroidal anti-inflammatories |
V58.65 | Long-term (current) use of steroids |
V58.69 | Encounter for other and unspecified procedures and after care; long-term (current) use of other medications |
V67.51 | Follow-up examination; following completed treatment with high-risk medication, NEC |
Note: Diabetic retinopathy must be coded using appropriate ICD-9-CM codes from 362.0X. Correct coding of 362.0X dictates primary coding with 250.50–250.51, but payment will not occur unless 362.0X is also reported.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Documentation Requirements
In order to determine medical necessity, a copy of the clinical records which must justify the diagnosis listed on the claim and the reason(s) that fundus photographs and the frequency with which they were repeated were necessary for planning therapy and monitoring the progress of the disease diagnosed may be requested.
Documentation must support the medical necessity of this service as outlined in the “Indications and
Limitations of Coverage and/or Medical Necessity” section of this policy.
Documentation in the patient’s medical record should include all of the following:
- A current pertinent history and physical examination, and progress notes describing and supporting the covered indication.
- Pertinent prior diagnostic testing and completed report(s). This would include, when appropriate, previous fundus photographs.
- The medical record must be made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
