92250

Short Definition

Fundus photography with interpretation and report

Long Definition

CPT code 92250 describes the photographic documentation of the posterior segment of the eye (fundus) with interpretation and generation of a written report by a physician. Fundus photography provides color photographic images of the retina, optic disc, macula, and retinal blood vessels, creating permanent documentation of the appearance of these structures at a specific point in time. The procedure involves using specialized retinal cameras to capture high-resolution digital images of the posterior pole and peripheral retina. Images may be obtained with or without pupil dilation, though dilation typically provides superior image quality.

The code includes image acquisition (technical component), physician interpretation of the images, and generation of a written report documenting findings. Fundus photography is valuable for documenting baseline retinal appearance, monitoring progression of retinal diseases (especially diabetic retinopathy and age-related macular degeneration), comparing changes over time, and providing visual documentation for medical records, patient education, and teleophthalmology applications. This is distinctly different from fluorescein angiography (92235), which involves intravenous dye injection and captures dynamic vascular filling patterns, or OCT imaging (92134), which provides cross-sectional structural imaging.

Area of Body

Posterior segment of the eye (fundus), including:

• Optic disc (optic nerve head):
  • Cup-to-disc ratio
  • Disc color and margins
  • Neuroretinal rim
  • Peripapillary region
• Macula:
  • Fovea (central depression)
  • Foveal reflex
  • Macular pigmentation
  • Drusen
  • Exudates or hemorrhages
  • Macular edema appearance
• Retinal blood vessels:
  • Arterioles and venules
  • Vascular caliber
  • Arteriovenous crossing changes
  • Vascular tortuosity
  • Hemorrhages
  • Microaneurysms
• Peripheral retina:
  • Peripheral lesions
  • Retinal breaks or tears
  • Peripheral hemorrhages
  • Lattice degeneration
• Retinal pathology:
  • Hemorrhages (dot-blot, flame-shaped)
  • Exudates (hard exudates, cotton-wool spots)
  • Drusen
  • Pigmentary changes
  • Atrophic areas
  • Neovascularization

Service Components

Included Services:

• Image acquisition using specialized fundus camera
• Multiple images of posterior pole and/or peripheral retina
• Technical component: Operation of camera, patient positioning, focusing, image capture, image quality assessment
• Image storage in digital format
• Professional component: Physician interpretation of photographs
• Written report documenting findings
• Comparison to prior photographs when available
• Documentation of significant findings
• Correlation with clinical examination

Standard Photography Protocols:

• Macula-centered view: Central 30-45 degree field capturing macula and optic disc
• Optic disc-centered view: Focused on optic nerve head
• Additional fields: May include peripheral views, wide-field imaging, or specific areas of pathology
• Stereo photography: Paired images for three-dimensional assessment (when performed)
• Red-free photography: Using green filter to enhance retinal nerve fiber layer and vascular detail (when performed)

Excludes:

• Fluorescein angiography (92235 - IV dye injection, dynamic imaging)
• Indocyanine green angiography (92240 - different dye, choroidal imaging)
• Fundus autofluorescence (often bundled or separate unlisted code depending on payer)
• OCT imaging (92132-92134, 92137 - cross-sectional imaging, different modality)
• Extended ophthalmoscopy with retinal drawing (92225-92226 - examination service, not photography)
• Ophthalmic photography without interpretation (99000 series or unlisted codes)
• Anterior segment photography (typically unlisted code)
• External eye photography (unlisted code or 99000)

May Be Bundled By NCCI:

• Some payers bundle 92250 with OCT codes (92133, 92134)
• Check current NCCI edits before billing both same day
• May need modifier 59 with documentation of medical necessity for both

Separately Billable When Appropriate:

• Examination codes (92002-92014)
• OCT imaging (92132-92134, 92137) - if NCCI allows or modifier used
• Visual field testing (92081-92083)
• Fluorescein angiography (92235) - different modality
• Procedures performed same day

RVU Information

Work RVU (wRVU): 0.61
Facility Total RVU: Approximately 0.91
Non-Facility Total RVU: Approximately 1.50
Global Days: XXX (diagnostic test, no global period)
Medicare Status: Active/Payable when medically necessary
2026 Medicare National Average:

• Facility: Approximately $29-32
• Non-Facility: Approximately $49-54
  (Varies by geographic locality and MAC)

RVU Comparison to Related Codes:

• 92250 (fundus photography): 0.61 wRVU
• 92133 (OCT optic nerve): 0.52 wRVU
• 92134 (OCT retina): 0.52 wRVU
• 92235 (fluorescein angiography): 1.07 wRVU (higher, more complex procedure)
• 92240 (ICG angiography): 1.07 wRVU

Historical Context:

• RVUs relatively stable over time
• Lower RVU than angiography due to simpler technique
• Photography is quick, non-invasive, no IV access required

HCC Status

Not Applicable - HCC coding applies only to ICD-10 diagnosis codes, not CPT procedure codes. However, retinal diagnoses documented through fundus photography may map to HCC categories (e.g., diabetic retinopathy - HCC 122) and should be coded accurately.

Assistant Surgeon Status

Assistant Payable: Not Applicable

CPT 92250 is a diagnostic imaging service, not a surgical procedure. The concept of assistant surgeon does not apply. Assistant surgeon modifiers (80, 81, 82, AS) are never used with diagnostic imaging or photography services.

Common Modifiers

Modifier	Description	Usage Frequency	Application	Notes
26	Professional component only	Moderate-High	Interpretation without performing photography	Physician reads images taken elsewhere
TC	Technical component only	Moderate-High	Photography without interpretation	Facility or photographer bills for image acquisition
59	Distinct procedural service	Low-Moderate	May bypass NCCI with OCT	Requires documentation of separate medical necessity
XE	Separate encounter	Low	Alternative to 59	X-modifier more specific
XS	Separate structure	Low	Alternative to 59	Different anatomic area
XP	Separate practitioner	Low	Alternative to 59	Different provider
XU	Unusual non-overlapping	Low	Alternative to 59	Distinct service
76	Repeat procedure by same physician	Low	Repeat photography same day	Poor image quality, additional views needed
77	Repeat procedure by different physician	Rare	Different photographer repeats	Unusual circumstance
52	Reduced services	Rare	Limited photography	Fewer images than standard
GY	Statutorily excluded	Low	Non-covered by Medicare	Screening without medical necessity
GA	Waiver of liability on file	Low	ABN obtained	When coverage uncertain
GZ	Expected denial	Low	Service expected to deny	ABN not obtained
RT	Right side	Not standard	Generally not used	Code typically includes bilateral
LT	Left side	Not standard	Generally not used	Code typically includes bilateral

Critical Modifier Information:

Modifier 26 and TC (Most Common):

• Global (no modifier): Both image acquisition and interpretation = full payment
• Modifier -TC (technical): Photography only without interpretation
  • Approximately 60% of total RVU
  • Billed by facility, photographer, or technician’s employer
  • Includes equipment, supplies, staff time
• Modifier -26 (professional): Interpretation and report only
  • Approximately 40% of total RVU
  • Billed by physician interpreting images
  • Must generate written interpretation report

Split Billing Example:

• Hospital outpatient performs fundus photography: Bills 92250-TC
• Ophthalmologist interprets images: Bills 92250-26
• Combined payment equals global fee

Modifier 59 and X-Modifiers:

• Used when NCCI bundles 92250 with another code
• Most common scenario: Billing 92250 with OCT same day
• Must document separate medical necessity
• X-modifiers (-XE, -XS, -XP, -XU) provide more specificity than -59
• Payer may still deny even with modifier if considers services duplicative

Modifiers NOT Typically Used:

• -50 (bilateral): Fundus photos typically include both eyes; per-encounter code
• -51 (multiple procedures): Auto-applied by payers
• -RT/-LT: Not standard; photography typically bilateral
• -22 (increased services): Not applicable to photography

Common Associated CPT Codes

CPT Code	Description	Relationship to 92250	Billing Considerations
92002-92014	Eye examination codes	Same encounter typical	Separately billable, different service types
92133	OCT optic nerve	May be bundled	NCCI may bundle 92250 into OCT; check edits
92134	OCT retina	May be bundled	NCCI may bundle 92250 into OCT; check edits
92235	Fluorescein angiography	Different modality	Separately billable; both may be clinically indicated
92240	ICG angiography	Different modality	Separately billable
92081-92083	Visual field testing	May be associated	Separately billable
92020	Gonioscopy	May be associated	Separately billable
67028	Intravitreal injection	Commonly associated	Separately billable; photos document baseline/response
67210	Laser photocoagulation	May be associated	Photos document treatment areas
67228	Laser for retinal disease	May be associated	Pre/post-treatment documentation
92018	Ophthalmological exam under anesthesia	Pediatric cases	Photography may be performed during exam

Common Service Combinations:

Diabetic Retinopathy Screening:

• 92012 or 92014 (examination)
• 92250 (fundus photography for documentation)
• Commonly used in diabetic screening programs

Fundus Photography with OCT:

• 92012 or 92014 (examination)
• 92250 (fundus photography)
• 92134 (OCT retina)
• Check NCCI: May need modifier 59 on 92250 if bundled

Injection Therapy Monitoring:

• 92012-25 (examination with modifier 25)
• 92250 (photos document baseline or treatment response)
• 67028 (intravitreal injection)
• All separately billable with appropriate documentation

Angiography with Photography:

• 92012 or 92014 (examination)
• 92250 (color fundus photos)
• 92235 (fluorescein angiography)
• Both imaging modalities may be needed for complete assessment

Code Tree/Hierarchy

CPT Manual Section: Medicine (90000-99999)
Subsection: Ophthalmology (92002-92499)
Major Category: Special Ophthalmological Services (92018-92499)
Subcategory: Ophthalmoscopy (92225-92260)
Service Type: Fundus Photography
Code: 92250

Ophthalmoscopy and Imaging Code Family:

Ophthalmoscopy and Retinal Imaging (92225-92260)
├── Extended Ophthalmoscopy
│   ├── 92225 - Extended ophthalmoscopy, initial
│   └── 92226 - Extended ophthalmoscopy, subsequent with drawing
│
├── Fundus Photography
│   └── 92250 - Fundus photography with interpretation and report ◄ Current Code
│
└── Angiography
    ├── 92235 - Fluorescein angiography
    └── 92240 - Indocyanine green (ICG) angiography

Related Imaging Modalities:

Posterior Segment Imaging Technologies
├── Photographic Imaging
│   ├── 92250 - Color fundus photography ◄ Current Code
│   ├── Unlisted - Fundus autofluorescence (payer-dependent)
│   └── Unlisted - Wide-field imaging (often bundled into 92250)
│
├── Cross-Sectional Imaging (OCT)
│   ├── 92133 - OCT optic nerve
│   ├── 92134 - OCT retina
│   └── 92137 - OCT retina with angiography
│
└── Dynamic Vascular Imaging
    ├── 92235 - Fluorescein angiography
    └── 92240 - ICG angiography

Code Selection Decision Tree:

Need Posterior Segment Imaging?
│
├── COLOR PHOTOGRAPHIC DOCUMENTATION needed?
│   └── 92250 - Fundus photography ◄ Current Code
│       Uses: Baseline documentation, disease progression monitoring,
│       diabetic screening, teleophthalmology, medical-legal documentation
│
├── CROSS-SECTIONAL STRUCTURAL IMAGING needed?
│   └── OCT codes (92132-92134, 92137)
│       Uses: Quantify retinal thickness, detect fluid, assess layers
│
├── DYNAMIC VASCULAR IMAGING needed?
│   ├── 92235 - Fluorescein angiography
│   │   Uses: Detect leakage, vascular occlusions, CNV, capillary non-perfusion
│   └── 92240 - ICG angiography
│       Uses: Choroidal vasculature, central serous, polypoidal choroidal vasculopathy
│
└── COMPREHENSIVE EXAMINATION with detailed drawing?
    └── 92225-92226 - Extended ophthalmoscopy
        Uses: Detailed clinical exam with artistic rendering of findings

Complementary Nature of Imaging Modalities:

• Fundus photography (92250): Provides color documentation, baseline comparison
• OCT (92134): Quantifies thickness, detects fluid, assesses layers
• Fluorescein angiography (92235): Shows vascular leakage and perfusion
• Multiple modalities often clinically indicated for complete assessment
• Each provides unique information not available from others

Coding Examples

Example 1: Diabetic Retinopathy Screening and Documentation

Patient Presentation: 52-year-old established patient with Type 2 diabetes mellitus for 12 years, presents for annual diabetic eye examination. Last eye exam 14 months ago.

History:

• Type 2 diabetes, HbA1c 7.8% (fair control)
• On metformin and glargine insulin
• No visual complaints
• Last dilated eye exam showed minimal diabetic changes

Examination:

• Visual acuity: 20/25 OU
• IOP: 15 mmHg OU
• Anterior segment: Normal
• Dilated fundus examination:
  • Scattered microaneurysms and dot-blot hemorrhages OU
  • Few hard exudates temporal to macula OU
  • No cotton-wool spots
  • No neovascularization
  • Optic discs normal

Fundus Photography Performed:

• Color fundus photographs obtained both eyes
• Macula-centered and disc-centered views
• Multiple peripheral fields

Images Captured:

• Right eye: 3 fields (macula, disc, temporal periphery)
• Left eye: 3 fields (macula, disc, temporal periphery)
• Total: 6 images

Interpretation Report:
“Color fundus photography demonstrates findings consistent with mild non-proliferative diabetic retinopathy bilaterally. Scattered microaneurysms and small hemorrhages are present in the posterior pole both eyes. Several hard exudates noted temporal to the macula bilaterally, outside the foveal avascular zone. No cotton-wool spots or neovascularization identified. Comparison to photographs from [prior date] shows slight increase in number of microaneurysms and hemorrhages, indicating mild progression. Optic discs appear normal without edema or neovascularization. Findings correlate with clinical examination.”

Assessment: Mild non-proliferative diabetic retinopathy OU, mild progression from prior

Plan: Continue medical management of diabetes, return in 6 months for follow-up, reinforce importance of glucose control

Coding:

• 92014 - Comprehensive ophthalmological examination, established patient
• 92250 - Fundus photography with interpretation and report

Diagnoses:

• E11.329 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye (can specify laterality)
• E11.9 - Type 2 diabetes mellitus without complications

Medical Necessity: Fundus photography medically necessary for:

• Documentation of diabetic retinopathy severity
• Baseline for monitoring progression
• Compliance with diabetic care guidelines
• Medical-legal documentation
• Comparison at future visits

Example 2: Age-Related Macular Degeneration Monitoring

Patient: 78-year-old established patient with known intermediate dry AMD OU, presents for 6-month follow-up.

History:

• Intermediate dry AMD with drusen
• Taking AREDS2 vitamins
• No new visual symptoms
• Monitors with Amsler grid at home daily

Examination:

• Visual acuity: 20/30 OU (stable)
• Dilated fundus exam: Multiple medium-large drusen both eyes, no hemorrhage or subretinal fluid visible

Fundus Photography:

• Color fundus photographs obtained to document drusen distribution and any changes
• Stereo pairs of macula for three-dimensional assessment

Interpretation:
“Color fundus photography demonstrates multiple medium and large soft drusen scattered throughout the macula bilaterally. Drusen distribution is similar to prior examination dated [date] with no significant interval change. No hemorrhages, exudates, or pigmentary changes suggestive of conversion to wet AMD identified. Findings consistent with intermediate dry age-related macular degeneration, stable.”

Assessment: Intermediate dry AMD OU, stable

Plan: Continue AREDS2 vitamins, home Amsler grid monitoring, return in 6 months, patient educated on warning signs of wet AMD

Coding:

• 92012 - Intermediate eye examination, established patient
• 92250 - Fundus photography

Diagnosis:

• H35.3122 - Nonexudative age-related macular degeneration, left eye, intermediate dry stage
• H35.3121 - Nonexudative age-related macular degeneration, right eye, intermediate dry stage

Medical Necessity: Photography necessary for:

• Monitoring drusen progression
• Detecting early conversion to wet AMD
• Documenting stability vs change over time
• Comparison with future examinations

Example 3: Photography with OCT - NCCI Bundling Consideration

Patient: 65-year-old with new diagnosis of branch retinal vein occlusion (BRVO) right eye with macular edema.

Services Performed:

• Comprehensive examination
• Color fundus photography: Document vascular changes, hemorrhages, location of BRVO
• OCT retina: Quantify macular edema, measure retinal thickness

Coding Scenario:

Option 1: If Payer Bundles 92250 into OCT:

• 92014 - Comprehensive exam
• 92134 - OCT retina (92250 bundled, not separately paid)
• Do NOT bill 92250 separately

Option 2: If Payer Allows Both:

• 92014 - Comprehensive exam
• 92134 - OCT retina
• 92250 - Fundus photography (if separately billable)

Option 3: If NCCI Edit Exists But Both Clinically Necessary:

• 92014 - Comprehensive exam
• 92134 - OCT retina
• 92250-59 - Fundus photography with modifier 59 (or X-modifier)

Documentation to Support Modifier 59:
Must document distinct clinical purposes:

• “Fundus photography performed to document distribution and extent of retinal hemorrhages, location of vascular occlusion, and areas of ischemia for treatment planning and medical-legal documentation”
• “OCT imaging performed separately to quantify macular thickness, assess intraretinal and subretinal fluid, and guide anti-VEGF therapy decisions”
• “Both modalities provide complementary information not obtainable from the other and both are necessary for complete assessment”

Diagnosis:

• H34.8311 - Tributary (branch) retinal vein occlusion, right eye, with macular edema

Practical Approach:

• Check current NCCI edits
• Verify payer-specific bundling policies
• When in doubt, bill both and let payer adjudicate
• Appeal if clinical necessity is clear but payment denied

Example 4: Teleophthalmology/Diabetic Screening Program

Setting: Community health center with diabetic screening program using telemedicine

Patient: 58-year-old with Type 2 diabetes, no eye exam in 3 years, limited access to ophthalmologist

Service: Non-mydriatic fundus photography performed by trained technician

Workflow:

1. Technician obtains color fundus photos (technical component)
2. Images transmitted electronically to remote ophthalmologist
3. Ophthalmologist interprets images and generates report (professional component)

At Screening Site:

• Billing: 92250-TC (technical component only)
• Performed by: Community health center
• Equipment: Non-mydriatic fundus camera

Remote Interpretation:

• Billing: 92250-26 (professional component only)
• Performed by: Ophthalmologist at different location
• Service: Interpretation and report generation

Interpretation Report:
“Teleophthalmology color fundus photography demonstrates mild non-proliferative diabetic retinopathy with scattered microaneurysms and small hemorrhages bilaterally. Image quality is adequate for screening purposes. No evidence of macular edema, cotton-wool spots, or neovascularization on available images. Recommend in-person comprehensive eye examination with OCT imaging to fully assess macular status and to perform visual field testing.”

Result: Patient referred for in-person comprehensive examination

Coding:

• Community health center bills: 92250-TC
• Ophthalmologist bills: 92250-26

Diagnosis:

• E11.329 - Type 2 DM with mild NPDR without macular edema

Medical Necessity: Diabetic retinopathy screening per ADA guidelines; teleophthalmology increases access to screening in underserved area.

Example 5: Pre- and Post-Laser Photocoagulation Documentation

Patient: 62-year-old with proliferative diabetic retinopathy, scheduled for panretinal photocoagulation (PRP) laser.

Pre-Laser Photography:

• Color fundus photos document extent of neovascularization
• Wide-field imaging captures peripheral retinal changes
• Photos show areas planned for laser treatment

Post-Laser Photography (Different Date):

• Photos document laser scars
• Confirm adequate coverage
• Monitor regression of neovascularization

Coding:
Visit 1 (Pre-Laser):

• 92014 - Comprehensive exam
• 92250 - Fundus photography
• 92235 - Fluorescein angiography (if performed)
• 67228 - Laser treatment (if performed same day)

Visit 2 (Post-Laser, 2 Weeks Later):

• 92012 - Intermediate exam
• 92250 - Fundus photography (to document treatment effect)

Diagnosis:

• E11.3513 - Type 2 DM with proliferative diabetic retinopathy with macular edema, bilateral

Medical Necessity for Photography:

• Pre-treatment: Document baseline, plan treatment areas
• Post-treatment: Confirm adequate laser application, document response, medico-legal protection

Example 6: Photography Cannot Replace OCT

Patient: 68-year-old with known wet AMD on monthly injections. Requests “just photos” today instead of OCT to save money.

Clinical Situation:

• Patient needs monitoring of subretinal fluid to guide anti-VEGF therapy
• Fundus photography alone CANNOT quantify fluid or assess treatment response adequately
• OCT is standard of care for monitoring wet AMD treatment

Physician Response:
“While fundus photography can document the appearance of your retina, it cannot show us the fluid under your retina or measure the thickness of your retina the way OCT can. OCT is necessary to determine if your injections are working and whether we need to adjust your treatment. Photography alone would not provide adequate information to make treatment decisions.”

If Patient Still Declines OCT:

• Document patient declined recommended OCT
• Perform fundus photography if patient agrees
• Document limitations in medical record
• May need to defer injection decision without OCT data

Coding:

• 92012 - Examination
• 92250 - Fundus photography (if performed)
• Do NOT bill 92134 if not performed
• Document patient refusal of recommended testing

Key Point: Fundus photography and OCT provide different, complementary information. Photography is 2D surface documentation; OCT is cross-sectional structural imaging. Cannot substitute one for the other in many clinical situations.

Documentation Requirements

Medical Necessity Documentation:

Clinical Indication Required:

• Signs, symptoms, or findings supporting need for fundus photography
• How images will impact diagnosis or treatment decisions
• Baseline documentation for future comparison
• Monitoring known retinal disease progression
• Pre- or post-treatment documentation

Common Indications Supporting Medical Necessity:

• Diabetic retinopathy screening or monitoring
• Age-related macular degeneration (baseline and follow-up)
• Retinal vascular occlusions
• Hypertensive retinopathy
• Optic disc abnormalities (edema, pallor, cupping)
• Suspicious retinal lesions (choroidal nevus, suspected melanoma)
• Retinal dystrophies or degenerations
• Pre-operative documentation (cataract surgery, retinal surgery)
• Post-operative monitoring
• Documentation of treatment response (laser, injections)
• Teleophthalmology/telemedicine applications
• Medical-legal documentation
• Research protocols (with patient consent)

Interpretation Report Must Contain:

Required Elements:

1. Patient Demographics:
   • Patient name, date of birth, medical record number
   • Date images obtained
   • Ordering physician if different from interpreter
2. Technical Information:
   • Type of camera used (e.g., non-mydriatic, mydriatic, wide-field)
   • Number of images obtained
   • Fields imaged (macula-centered, disc-centered, peripheral)
   • Laterality (OD, OS, OU)
   • Image quality (excellent, good, fair, poor, inadequate)
   • Use of mydriasis (dilated vs non-dilated)
   • Special techniques (stereo pairs, red-free, etc.)
3. Findings - Systematic Description:

Optic Disc:

• Size and shape
• Color (pink, pale, hyperemic)
• Cup-to-disc ratio
• Neuroretinal rim (intact, thinning, notching)
• Disc margins (sharp, blurred)
• Optic disc edema or pallor
• Peripapillary changes
• Presence of hemorrhages

Macula:

• Foveal reflex (present, absent, abnormal)
• Pigmentation (normal, hypopigmented, hyperpigmented)
• Drusen (number, size, type, distribution)
• Hard exudates
• Hemorrhages
• Evidence of edema (clinical appearance)
• Atrophic changes
• Epiretinal membrane or macular pucker
• Subretinal fluid or hemorrhage (if visible)

Retinal Vessels:

• Caliber (normal, attenuated, dilated)
• Arteriovenous ratio
• Arteriovenous crossing changes
• Tortuosity
• Sheathing
• Hemorrhages (type and distribution)
• Microaneurysms
• Cotton-wool spots
• Venous beading
• Intraretinal microvascular abnormalities (IRMA)
• Neovascularization (disc or elsewhere)

Peripheral Retina:

• Peripheral hemorrhages or exudates
• Retinal breaks, tears, or detachments
• Lattice degeneration
• Laser scars (if post-treatment)
• Peripheral neovascularization
• Vitreoretinal interface abnormalities

Other Findings:

• Choroidal lesions (nevi, melanoma)
• Retinal pigment epithelial changes
• Subretinal lesions
• Any other significant abnormalities

4. Comparison to Prior Studies:
   • Date of prior photography
   • Specific comparison of key findings
   • Changes noted: stable, improved, progressed
   • Quantify progression when possible (e.g., “number of microaneurysms increased from approximately 15 to 30”)
5. Clinical Correlation:
   • Correlation with clinical examination
   • Correlation with symptoms
   • Correlation with visual acuity
   • Correlation with other imaging (OCT, angiography)
6. Impression/Conclusion:
   • Summary of significant findings
   • Primary diagnosis(es)
   • Recommendations for management
   • Suggested follow-up imaging interval
   • Need for additional testing
7. Physician Signature:
   • Interpreting physician name and credentials
   • Date of interpretation
   • Electronic or written signature

Image Storage and Quality:

• Digital images must be stored and retrievable
• Images should be of diagnostic quality
• Poor quality images should be noted in report with explanation
• Images should be part of permanent medical record
• HIPAA-compliant storage required
• Key images should be available for review
• Image file naming and organization system for easy retrieval

Documentation Pitfalls to Avoid:

• Generic template report without patient-specific findings
• Missing comparison to prior photographs when available
• Inadequate description of significant pathology
• No physician signature or credentials
• Stating “see images” without written interpretation
• Poor image quality without documentation of limitation
• Images obtained but no interpretation report generated
• Copy-paste errors from prior reports
• Missing laterality designation (OD vs OS)
• Incomplete image capture without documentation of reason

Billing Guidelines and Best Practices

Bilateral vs Unilateral Imaging:

Standard Practice:

• Fundus photography code 92250 typically includes bilateral imaging
• Bill ONE unit whether photographing one eye or both eyes
• Most fundus photography sessions include both eyes
• Do NOT bill 92250 twice for bilateral
• Do NOT use modifier 50
• Generally do NOT use RT/LT modifiers (not per-eye code)

Exception - Unilateral Only:

• If only one eye photographed (medical contraindication to imaging fellow eye, patient cooperation limited to one eye)
• Still bill 92250 without modifier (code includes unilateral or bilateral)
• Document reason only one eye imaged
• Payment same whether one or both eyes

Professional vs Technical Component:

Global Service (No Modifier):

• Includes both image acquisition AND physician interpretation
• Full payment
• Provider performs photography and interprets

Split Billing:

• Modifier TC: Technical component (photography)
  • Image acquisition, equipment, staff, supplies
  • Approximately 60% of total RVU
  • Billed by facility or photographer
  • Does NOT include interpretation
• Modifier 26: Professional component (interpretation)
  • Physician interpretation and report
  • Approximately 40% of total RVU
  • Requires written interpretation report
  • Billed by interpreting physician

Common Split Billing Scenarios:

• Hospital outpatient department: Bills 92250-TC
• Interpreting ophthalmologist: Bills 92250-26
• Teleophthalmology: Photographer bills TC, remote physician bills 26
• Total: TC + 26 = global payment

NCCI Edits and Bundling:

Critical Issue - OCT Bundling:

• NCCI may bundle 92250 (fundus photography) into OCT codes (92133, 92134, 92137)
• Edit status changes over time; check current version
• If bundled: OCT payment includes photography; cannot bill 92250 separately
• Some payers always bundle; others allow with modifier

If Both Clinically Necessary:

• Use modifier 59 (or X-modifier: XE, XS, XP, XU) on 92250
• Document separate medical necessity
• Explain why BOTH modalities provide unique, non-duplicative information
• Examples of justification:
  • “Fundus photography provides color documentation of hemorrhage distribution and location for treatment planning; OCT quantifies macular thickness and fluid for treatment response monitoring”
  • “Photography documents optic disc appearance and NFL defects; OCT measures RNFL thickness for glaucoma staging”
  • “Both modalities clinically necessary and provide complementary, non-overlapping diagnostic information”
• Be prepared for potential denial even with modifier
• Consider appealing with clinical rationale

Codes Bundled with 92250 (Check Current NCCI):

• May bundle with 92133, 92134, 92137 (OCT codes)
• Extended ophthalmoscopy (92225-92226) may have edits

Separately Billable with 92250:

• Examination codes (92002-92014)
• Fluorescein angiography (92235) - different modality
• ICG angiography (92240) - different modality
• Visual field testing (92081-92083)
• Procedures (injections, laser)

Frequency and Medical Necessity:

Medicare Guidelines:

• No specific frequency limitation for 92250
• Each test must be medically necessary
• Document clinical indication for photography
• Frequency depends on condition severity and stability

Reasonable Frequency Guidelines:

• Diabetic retinopathy:
  • Stable no DR or mild NPDR: Annually
  • Moderate-severe NPDR: Every 3-6 months
  • PDR or DME on treatment: Monthly to quarterly
  • Post-PRP laser: 1-3 months, then less frequently
• Age-related macular degeneration:
  • Dry AMD with drusen: Every 6-12 months
  • Intermediate AMD: Every 6 months
  • Wet AMD on treatment: Monthly (though OCT more common)
• Other retinal conditions:
  • As clinically indicated based on severity and stability
  • Document need for interval monitoring
• Baseline/comparison:
  • Initial diagnosis: Medically necessary
  • Periodic monitoring: Document changes being monitored

Not Covered:

• Routine screening without clinical indication
• More frequent than medically necessary for condition
• When results won’t change management
• Purely for patient education without diagnostic purpose
• Research purposes without medical necessity (requires patient consent, typically not billable)

Medical Necessity Documentation:

• Clinical indication clearly stated
• How photos will guide management
• Specific findings being monitored
• Comparison to prior as baseline

Prior Authorization:

• Medicare: Generally not required for 92250
• Medicare Advantage: May require authorization (check plan)
• Commercial payers: Variable policies
• Teleophthalmology programs: Often require prior authorization or special enrollment

Advance Beneficiary Notice (ABN):

When to Provide ABN:

• Medicare beneficiary and coverage uncertain
• Frequency may exceed typical medical necessity
• Screening indication without symptoms or findings
• Patient requests photography for personal records without medical indication

Modifier Use with ABN:

• GA modifier: ABN signed by patient agreeing to pay if denied
• GZ modifier: Service expected to deny, ABN not obtained (high audit risk)
• GY modifier: Statutorily excluded service (non-covered by Medicare)

Teleophthalmology Considerations:

Coverage Policies Vary:

• Medicare: Limited coverage for teleophthalmology in certain settings
• State Medicaid programs: Variable coverage
• Commercial payers: Increasing coverage for telemedicine
• May require enrollment in approved teleophthalmology network
• Split billing (TC/26) common in teleophthalmology

Documentation Requirements:

• Store-and-forward vs real-time interpretation
• Security and HIPAA compliance
• Image transmission method
• Quality assurance protocols
• Patient consent for telemedicine

Diabetic Retinopathy Screening Programs:

• Some payers have special billing codes or programs
• May bundle photography with interpretation into single fee
• Quality metrics and reporting requirements
• Consider population health management contracts

Common Billing Errors to Avoid:

1. Billing twice for bilateral photography - Code includes both eyes; bill once
2. Using modifier 50 or RT/LT separately - Not per-eye code
3. Billing without interpretation report - Professional component requires documentation
4. Inadequate medical necessity - Must document clinical indication
5. Billing for screening without findings - Medicare doesn’t cover routine screening
6. Poor image quality without documentation - Note technical limitations if images suboptimal
7. Not checking NCCI edits before billing with OCT - May be bundled
8. Missing physician signature on interpretation - Required for professional component
9. Billing TC without proper equipment/staff - Must actually perform photography
10. Billing 26 without generating written report - Report required for professional component
11. Copy-paste errors in interpretation - Individualize each report
12. Billing for images stored but never interpreted - Professional component requires interpretation

Best Practices:

Documentation:

• Individualized interpretation report (avoid generic templates)
• Specific findings with anatomic detail
• Comparison to prior studies when available
• Clinical correlation documented
• Clear impression and recommendations
• Physician signature with credentials

Medical Necessity:

• Document clinical indication clearly in exam note
• Explain how photos will guide diagnosis or treatment
• Appropriate frequency for condition severity
• Link findings to diagnosis codes

Image Quality:

• Ensure diagnostic quality images
• Document technical limitations if present (small pupil, media opacity, patient cooperation issues)
• Adequate number of images for clinical question
• Proper image labeling and storage

Compliance:

• Follow NCCI bundling rules
• Appropriate modifier use when needed
• Correct professional/technical component billing
• Accurate diagnosis coding
• Medical necessity documentation
• Prior authorization when required
• ABN when coverage uncertain

Billing Accuracy:

• Bill per-encounter, not per-eye
• Don’t unbundle when services included
• Split TC/26 appropriately in facility settings
• Check payer-specific policies
• Appeal denials with clinical documentation when appropriate

Telemedicine:

• Comply with state and federal telemedicine regulations
• HIPAA-compliant image transmission
• Appropriate consent
• Quality assurance for remote interpretation
• Proper TC/26 split billing
• Network enrollment if required

Quality Improvement:

• Regular review of interpretation reports for consistency
• Peer review of image quality
• Comparison correlation with clinical findings
• Audit of billing practices
• Stay current on coding updates and payer policies

Clinical Indications and Diagnosis Codes

Primary Diagnoses Supporting Medical Necessity:

Diabetic Retinopathy (Most Common Indication):

• E08.3xx-E13.3xx - Diabetes mellitus with ophthalmic complications (specify type)
• E11.311x - Type 2 DM with unspecified diabetic retinopathy with macular edema
• E11.319x - Type 2 DM with unspecified diabetic retinopathy without macular edema
• E11.321x-E11.329x - Type 2 DM with mild NPDR (with/without macular edema)
• E11.331x-E11.339x - Type 2 DM with moderate NPDR
• E11.341x-E11.349x - Type 2 DM with severe NPDR
• E11.351x-E11.359x - Type 2 DM with proliferative diabetic retinopathy (PDR)
• E11.36x - Type 2 DM with diabetic macular edema, resolved following treatment
• Sixth character specifies laterality and macular edema status

Age-Related Macular Degeneration:

• H35.30 - Unspecified macular degeneration
• H35.31x1-H35.31x4 - Nonexudative (dry) AMD (specify stage and laterality)
• H35.32x1-H35.32x4 - Exudative (wet) AMD (specify stage and laterality)
• H35.3611-H35.3633 - Drusen of macula (specify type and laterality)

Retinal Vascular Occlusions:

• H34.811x-H34.8393 - Central retinal vein occlusion (CRVO)
• H34.821x-H34.8393 - Branch retinal vein occlusion (BRVO)
• H34.11-H34.13 - Central retinal artery occlusion (CRAO)
• H34.21-H34.23 - Branch retinal artery occlusion (BRAO)

Hypertensive Retinopathy:

• H35.031-H35.039 - Hypertensive retinopathy
• I10 - Essential hypertension (supporting diagnosis)

Optic Disc Abnormalities:

• H47.10-H47.13 - Papilledema, unspecified
• H47.141-H47.149 - Foster-Kennedy syndrome
• H47.20-H47.239 - Optic atrophy
• H47.10-H47.13 - Papilledema
• H40.001-H40.9 - Glaucoma (optic disc cupping documentation)

Retinal Detachment:

• H33.001-H33.059 - Retinal detachment with retinal break
• H33.20-H33.23 - Serous retinal detachment

Macular Abnormalities:

• H35.341-H35.349 - Macular hole
• H35.371-H35.379 - Epiretinal membrane/macular pucker
• H35.721-H35.723 - Serous detachment of RPE
• H35.711-H35.713 - Central serous chorioretinopathy

Choroidal Lesions:

• D31.31-D31.32 - Benign neoplasm of choroid
• C69.31-C69.32 - Malignant neoplasm of choroid
• D49.81-D49.82 - Neoplasm of uncertain behavior of retina and choroid

Hereditary Retinal Dystrophies:

• H35.50-H35.54 - Hereditary retinal dystrophy
• H35.51-H35.52 - Vitreoretinal dystrophies
• H35.53 - Dystrophies primarily involving RPE

Other Retinal Disorders:

• H35.00-H35.07 - Background retinopathy and retinal vascular changes
• H35.171-H35.179 - Retinal telangiectasis
• H31.001-H31.129 - Chorioretinal scars
• H43.1xx - Vitreous hemorrhage

Post-Procedural/Treatment Monitoring:

• Z98.89 - Other specified postprocedural states
• Use with primary retinal diagnosis for post-treatment monitoring

Screening (Generally Not Covered by Medicare):

• Z13.5 - Encounter for screening for eye and ear disorders
• Note: Medicare doesn’t typically cover screening without findings
• Use specific finding code once abnormality detected

Diagnoses Generally NOT Supporting Medical Necessity:

• Routine eye examination without findings (Z01.00) - alone insufficient
• Refractive error alone (H52.xx) without retinal pathology
• Normal examination results without risk factors
• Purely cosmetic concerns

Supporting/Secondary Diagnoses:

• E11.9 - Type 2 diabetes mellitus without complications (if no retinopathy yet)
• I10 - Essential hypertension (for hypertensive retinopathy)
• Z79.4 - Long-term use of insulin (diabetes management context)
• Z79.84 - Long-term use of oral hypoglycemic drugs

Diagnosis Documentation Best Practices:

• Always code to highest specificity available
• Specify laterality (right, left, bilateral)
• For diabetes codes: Include type, retinopathy stage, macular edema status (6-character codes)
• For AMD: Specify dry vs wet, stage when known
• Use additional codes for underlying systemic conditions when relevant
• Link diagnosis to fundus photography findings in interpretation report
• Document progression when comparing to prior photographs
• If photography for screening in high-risk patient, document risk factors

ICD-10 Coding Tips for Fundus Photography:

• Primary diagnosis should be the retinal condition being documented/monitored
• Add diabetes type and control status for diabetic patients
• Include stage/severity when available in code set
• Use bilateral codes when both eyes affected
• Post-treatment monitoring: Use primary diagnosis plus Z98.89 if needed
• Don’t code findings visible only on photography if not clinically confirmed by physician examination