This article is more than 5 years old. Information may no longer be current.
Widefield fundus photography can be used as screening test
Patient comfort is enhanced by reducing the need for mydriatic drops and prolonged bright exam lights.
Click Here to Manage Email Alerts
Fundus photos are not covered by Medicare and commercial insurance carriers unless ordered to document pathology such as diabetic retinopathy, age-related macular degeneration, choroidal nevi, or vein or artery occlusion. Does a screening fundus photo in a Medicare patient require the patient to sign an Advance Beneficiary Notice that the study may not be covered by Medicare, so the patient is responsible for the charges?
An Advance Beneficiary Notice is required when Medicare reimbursement is unknown for a potentially covered service. However, according to feedback from the coding divisions of American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery, Medicare would not reimburse this charge because the service is considered a screening and therefore not covered. However, the patient needs to clearly understand why this service is not payable by the payer.
Even if pathology is found, the test is not billable to insurance because the pathology was unknown before the photos. If pathology is determined and subsequent testing is necessary, an order must be on file. Follow-up photos can then be submitted to the payer for payment, as it is no longer a screening exam.
In the practice of medicine, baseline chest X-ray, EKG and blood chemistries are routinely performed as screening tests and are covered by most health insurance. The idea of performing “screening” fundus photography, paid for by the patient, is not new. Optometrists have been doing this for years with the first widefield imaging system, the Optos. For the most part, this concept has not been embraced by ophthalmologists. Our practice in West Los Angeles has been considering this option for the past 2 years, and now we have initiated this for the past 2 months, using the new Zeiss Clarus camera, with encouraging results.
Source: Zeiss
Advantages of widefield fundus photos
Widefield fundus photographs allow a directed, more accurate fundus evaluation than traditional ophthalmoscopy by letting the examiner review the photographs on a monitor before the fundus exam and thus concentrate on and magnify any areas of interest, especially useful to see choroidal nevi, small cholesterol emboli and microaneurysms. This permits simpler, more accurate medical documentation and follow-up to establish stability or any potential development of new pathology relative to prior screening photos (Figure 1).
Patient comfort is enhanced by reducing the need for mydriatic drops in most cases, and both eyes are photographed in less than 5 minutes without the sustained bright light type exams on non-directed routine binocular indirect ophthalmoscopy (BIO) and 90D type exams. Milder dilating drops can often be used in these cases, but even with full/normal dilating drops, the patient experience is more comfortable, more efficient and more medically effective. Unlike the optometric protocol in which a fundus photo would replace a dilated exam and require an intermediate exam coding, our protocol legitimately retains a complete office visit coding with dilation and ophthalmoscopy. Furthermore, screening in this way streamlines office flow by providing the widefield photo before the patient sees the doctor.
Physician efficiency is improved by allowing a methodical focused exam of the entire retina, which is often challenging in traditional ophthalmoscopy due to patient discomfort with full dilation and bright exam lights and subsequent lid squeezing and erratic eye movements. “Screening” means the photos are taken by technicians before physician ophthalmoscopy, which streamlines patient flow by obviating the need for the patient’s return to the technician for imaging and then back to the physician for review and interpretation. These widefield photos typically result in a “wow” factor for patients by allowing them to immediately see the digital image in any exam room in the office and permit sharing of any pathology with referring doctors electronically. Patients who use smartphones can look forward to technology that will immediately wirelessly transfer images to their phone or be sent to them by email.
Screening fundus photos do not replace dilated ophthalmoscopy, but instead synergize and augment the doctor’s exam. Although the high-resolution stereoscopic doctor’s view through the BIO or 90D is arguably better than any existing camera, it simply is, at best, inefficient for the doctor and, at worst, arduous for the patient to scan the entire retina with the smaller field of view while looking for any pathology that would genuinely benefit from the BIO’s higher resolution. By almost instantaneously capturing a widefield retinal image, the patient’s discomfort is minimized, and the doctor can then scan at leisure, magnify, enhance with color filters, compare eyes for patient-specific physiologic variants, and only then subject the patient to the BIO’s (or 90D’s) brighter light to scrutinize any areas of interest identified by the screening photos.
Source: James J. Salz, MD
In addition to what we feel is superior patient care as outlined above, the new protocol has an additional benefit: In the era of progressively reduced insurance reimbursement, these photographs have been a significant new source of income payable at the time of the visit. Most patients in our practice have elected this option at a fee, which is the same as our fee for refraction, another common noncovered service (Figure 2). A useful aide to explain the advantages of widefield digital photography for evaluating the retina for signs of both eye pathology and systemic conditions is a 3-minute illustrated slide show by Rendia using an Apple iPad or a tablet. We of course also used the widefield camera for many eyes with known pathology such as macular degeneration, diabetic retinopathy and choroidal nevi and were reimbursed by Medicare or private insurance for fundus photos.
Widefield imaging systems
Optos ultra-widefield imaging systems capture 200° — more than 80% — of the retina in a single image and up to 220° in a montage view (Figure 3).
The Eidon CenterVue system provides 60° fields in a single exposure, 110° to 120° fields in auto-widefield mode and 150° fields in manual mode (Figure 4).
Source: Optos
Source: CenterVue
Source: Zeiss/Jay M. Haynie, OD, FAAO
Through sequential illumination by broad-spectrum red, green and blue light-emitting diodes, the Zeiss Clarus 500 also captures a 200° retina field (Figure 5).
Full descriptions of these imaging systems are available on the companies’ websites.
In our practice
We have developed a new paradigm and protocol for ophthalmologists to use the Clarus widefield photos as a screening test for routine patients. Unlike a related protocol used by optometrists for years, which tried to replace a dilated exam, our protocol augments the dilated exam by directing it. While an ophthalmologist’s stereo view through a BIO or 90D is arguably better than any photo, it simply does not make sense to put the patient through the additional time and discomfort it would take to use these modalities to scan every square millimeter of the (typically normal) retina while trying to build a mosaic image from memory even for a single eye, much less trying to compare such mosaics from memory between the two eyes.
A striking example of the value of fundus photos is patient CL, a 78-year-old man who presented with complaints of an upper field defect. Our technician performed his visual fields, which confirmed superior visual field defect (Figure 6).
The patient was vague about details of onset and duration, and I (JS) expected to find a possible retinal detachment. Indirect ophthalmoscopy revealed what I thought was a normal fundus. We took fundus pictures with our Nidek camera, which captures about a 30° view, which showed a Hollenhorst plaque in the inferior arteriole just below the optic nerve (Figure 7).
Summary of experience
In a summary of our experience over a 17-day period, our comprehensive ophthalmologist (JS) offered the widefield screening photos to 58 new and returning patients scheduled for a comprehensive eye exam. Forty-two patients (72%) chose to have the photographs of both eyes and paid the fee at the time of the visit.
The most common finding that was missed on ophthalmoscopy was fine macular (five patients) or paramacular (eight patients) drusen (Figure 8). This was no doubt due to our ability to view and enlarge the digital photographs on a 25-inch flat screen monitor without the patient moving and fighting the bright lights of an indirect ophthalmoscope (Figure 9).
Source: James J. Salz, MD
Source: James J. Salz, MD
We found microaneurysms or fine exudates in three patients with diabetes and one choroidal nevus (Figure 10). Thus, we found pathology in 17 of the 58 patients (29%) that was not noted on traditional retinal exams with direct and indirect ophthalmoscopy.
Summary
The addition of widefield fundus photography as a screening test has been the most important new technology for our practice since OCT for retina and glaucoma. Most of our patients have accepted the advantages of these photos as a screening test not covered by their health insurance. We feel we are providing better care while adding a new source of revenue to the practice.
This article does not intend to provide coding or regulatory advice and it is advised that providers check with their carriers for final clarification.
- References:
- CenterVue. www.centervue.com.
- Optos. www.optos.com.
- Zeiss. www.zeiss.com.
- For more information:
- James J. Salz, MD, can be reached at University of Southern California, USC Roski Eye Institute, 11620 Wilshire Blvd., Suite 711, Los Angeles, CA 90025; email: drjjsalz@gmail.com.
- Barry S. Seibel, MD, can be reached at email: idoc@vision-surgery.com.
Disclosures: Salz and Seibel report no relevant financial disclosures.