A look at the documentation and reimbursement of EOP.
Q What is external ocular photography?
A External ocular photography documents medical progress of the external eye, lids and ocular adnexa. Photographs record conditions and pathology of the adnexa, external eye and anterior segment more accurately than chart notes or drawings. They are used to track changes in patients’ abnormal conditions over time.
Q Do third-party payers reimburse for this diagnostic test?
A Medically necessary photos may be covered. The key points that justify coverage include that the photos:
- provide additional information not obtained during the exam;
- aid in diagnosis and treatment of a disease or condition; and
- are taken to assist in assessing disease progression.
Photographs taken merely to document disease are typically treated as an incidental part of an exam and are not separately reimbursed.
Some Medicare contractors have published verbiage in local policies stating, “… this procedure should not be used to simply document the existence of a condition in order to enhance the medical record.”
Q What CPT code is used to describe external ocular photography?
A CPT code 92285: External ocular photography with interpretation and report for documentation of medical progress, describes this service. For tear film imaging, CPT instructs providers to use 0330T.
Q What documentation is required in the medical record to support a claim for external ocular photos?
A In addition to the photos or proof that digital images exist, the chart should contain:
- an order for the test with medical rationale;
- the date of the test;
- the reliability of the test;
- the test findings (e.g., vascularization, opacity, defect, dellen, dendrites, neoplasm);
- comparison with prior tests;
- a diagnosis (if possible);
- the impact on treatment and prognosis;
- the signature of the physician.
Q What diagnoses support a claim for external ocular photography?
A Medicare local coverage determinations contain a variety of valid diagnoses for external ocular photos. The lists vary, but usually include diagnoses related to external and anterior segment diseases involving the lids, lacrimal system, cornea, conjunctiva, anterior chamber and iris.
Q Are there specific instructions regarding documentation with photos prior to eyelid surgery?
A Yes. Some Medicare contractors describe documentation expectations with photos prior to eyelid surgery. For example, a contractor’s requirements might resemble the following:
“COLOR photographs are required to support upper eyelid surgery as medically necessary. The ‘physical signs’ documented must be clearly represented in photographs of the structures of interest, and the photographs must be of sufficient size and detail as to make those structures easily recognizable. The patient’s head must be parallel to the camera and not tilted, so as not to distort the appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent measurement of a MRD). Digital or film photographs are acceptable. Photographs must be identified with the beneficiary’s name and the date.”
Q What is the frequency of external ocular photography?
A Medicare utilization rates for claims paid in 2015 show that external ocular photography was associated with 1 percent of all office visits to ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service one time. The utilization rate for optometry is about the same. Data for commercial payers is not published.
Q How often may this test be repeated?
A There are no national limitations for repeated testing. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. However, too-frequent testing can garner unwanted attention from Medicare and other third party payers.
Q Must the physician be present while this test is being performed?
A Under Medicare program standards, this test needs only general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Other payers generally agree.
Q What does Medicare allow for external ocular photography?
A CPT 92285 is defined as “bilateral” so reimbursement is for both eyes. The 2017 national Medicare Physician Fee Schedule allowable for 92285 is $21.17. Of this amount, $17.94 is assigned to the technical component, and $3.23 is the value of the professional component. Medicare allowable amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from Medicare’s published fee schedule.
External ocular photography is subject to Medicare’s Multiple Procedure Payment Reduction. This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.
Q If Medicare or other payer does not cover external ocular photography, may we charge the patient?
A Sometimes. Explain to the patient why the test is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms.
An Advance Beneficiary Notice of Noncoverage is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered.
For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits is an alternative to an ABN.
For Part C Medicare, determination of benefits is required to identify beneficiary financial responsibility prior to performing either noncovered or potentially noncovered services; MA Plans may each have their own process and waiver forms. Be sure to check.
Q Is external ocular photography bundled with other services?
A Yes. According to Medicare’s National Correct Coding Initiative, 92285 is bundled with the surgical codes for blepharoplasty procedures (15820-15824). Also, gonioscopy (92020) and the technician exam (99211) are bundled with external ocular photography. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.