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Fundus photos
The patient is financially responsible for a noncovered service, such as routine fundus photos.
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Your practice offers all patients the opportunity to have baseline fundus photos taken using a nonmydriatic camera as part of pre-testing. The photos are reviewed by your ophthalmologist or optometrist, and sometimes pathology is identified.
Can you claim reimbursement for these fundus photographs when pathology is found?
Medicare and other health insurance plans cover fundus photography if the patient presents with a complaint that leads you to perform this test or as an adjunct to management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, it is not covered (even if disease is identified).
Screening is differentiated from other diagnostic testing by several features:
- Screening is part of a wellness program to check for disease that may otherwise go undetected;
- Screening is not required by medical necessity; it is optional;
- The ophthalmologist or optometrist recommends the baseline fundus photos prior to every complete eye examination;
- The fundus photos are taken by a technician before the patient is seen by the ophthalmologist or optometrist; and
- All patients are screened unless they decline.
After the benefits of baseline fundus photos have been explained, the patient is advised of the extra charge for this service and may be asked to sign a financial waiver form. The patient is financially responsible for noncovered services.
In most cases, no claim will be filed with Medicare or a third-party payer because the patient is paying for a noncovered service and reimbursement is not sought. To avoid possible confusion at a later time, the patient’s statement should describe baseline fundus photos as “routine” and use V72.0 (routine exam of eyes and vision) to explain the service. If a Medicare beneficiary insists that you file a claim, then append modifier –GY to CPT 92250 to indicate a statutorily noncovered service. This modifier ensures a denial.
It is worth noting that subsequent evaluations and further testing based on pathology identified during screening are probably covered services for Medicare and other health plans. Reimbursement of your claim is reasonable provided that the chart documentation is complete and supportive.