This policy describes expanded coverage for special ophthalmoscopic procedures involving photography and adds covered guidelines for extended ophthalmoscopy.

Ocular photography and ophthalmoscopy are considered medically necessary for the following conditions:

• Extended ophthalmoscopy is covered when prolonged time is required for a detailed examination of possible retinal lesions or follow-up of lesions under treatment or surveillance.
  
  
• Fluorescein studies are useful in evaluation of the retinal vasculature, but this is a poor method for evaluating the choroidal vasculature because the retinal pigment obscures the dye.
  
  
• Fluorescein studies may be useful for patients on hydroxychloroqine sulfate with suspected toxicity. In order to meet approval for an additional study, at least one of the following criteria must apply:
  
  
  • The patient reports a change in vision, i.e., change in Amsler grid; or.
  • The physician's exam indicates a change in retinal findings, i.e., increased/decreased pigmentation.
    
    
• Fluorescein studies are not medically necessary for all patients with diabetic and other retinopathy; e.g., patients with background retinopathy but no evidence of diabetic macular edema generally do not require further evaluation.
  
  
• Fundus photography is clinically useful for following glaucoma and potentially progressive disorders of the retinal and choroidal structures which are amenable to therapy.
  
  
• External ocular photography is covered when a special camera is used to obtain magnified photographs of lesions (e.g., the cornea, iris or lids) for the purpose of following the patient's condition. Medical quality images may be of digital, Polaroid Macro 3 SLR or equivalent. Simple Polaroid photographs for the purpose of documenting for medicolegal purposes or preauthorization (e.g., gross trauma, amount of ptosis or redundant lid tissue) are not separately reimbursable since they are not medically necessary.
  
  
• Indocyanine green videoangiography (ICG) quadruples the ability to visualize occult subchoroidal neovascularization associated with age-related macular degeneration. It is used as an adjunct to fluorescein angiography or fundus photography.
  
  
• ICG is indicated to evaluate choroidal vasculatures. ICG-V is superior to IVFA in the assessment of choroidal hemangioma due to the specific angiographic features including early hyperfluorescence followed by later hypofluorescence. Indocyanine green videoangiography is significant in detecting intrinsic vessels and feeder vessels of a tumor.
  
  
• Optic nerve topography provides a laser image of the surface configuration of the optic nerve. Although a bilateral fundus photograph may be useful to follow disorders of the optic nerve, it may produce misleading results. Topography is reproducible and accurate.

Reasons for Noncoverage

Services provided for conditions not outlined on this policy will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Utilization Guidelines

• Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.
  
  
• Fundus photography - Generally, it is not medically necessary to repeat fundus photography more often than every 2 years for follow-up of stable glaucoma. Repeat photographs for retinopathy are rarely necessary.
  
  
• Fluorescein angiography - It is usually not necessary to repeat fluorescein angiography in patients who have only background retinopathy, (diagnosis code 362.01). Annual fluorescein angiography usually suffices for patients with stable and purely proliferative diabetic retinopathy, (diagnosis code 362.02). Patients with subretinal neovascularization, age-related macular degeneration, or following laser treatment may require more frequent follow-up.

Documentation Requirements

• The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.
  
  
• For consideration of codes 92225-92226 (extended ophthalmoscopy with retinal drawing), retinal pathology must be present to justify detailed examination. The retinal drawing should be labeled and include major landmarks, lesions and surrounding pathology. As an example, a drawing should provide sufficient detail as to the extent of a retinal detachment or the location of retinal holes in relation to major structures. Areas of traction, vitreous opacities, hemorrhage, etc. should all be drawn and clearly labeled to facilitate follow-up, referral to another physician, or purposed surgical treatment of the patient. A brief verbal interpretation of the findings is also required. 
  

• Appropriate photographs (referenced in the Indications and Limitations of Coverage section) must be in the patient’s record when codes 92230-92250 or ICG studies are billed.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Fundus Photography (CPT code 92250)and External Ocular Photography (CPT code 92285)are considered bilateral procedures. When performed unilaterally submit with CPT modifer 52 (Reduced Service). Do not submit with CPT modifer 50 (bilateral)or HCPCS modifer RT or LT.

This information was from Article A49285 which was retired on June 18, 2011.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

On-Line Manual 100-03, Chapter 1, Section 80.2

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.

Codes 92225-92226 - Extended Ophthalmoscopy