Unveiling the Truth: Identifying Medically Unnecessary Fundus Photography

Eyes, often dubbed the "windows to the soul," are also key to some of our health secrets. In the world of eye care, fundus photography acts as our special lens, offering insights into the eye's intricate structures. But what happens when this vital tool is misused, leading to medically unnecessary tests, blurred vision, and potential overpayment? In this article, I wanted to review a process of identifying medically unnecessary fundus photography services within a payer’s provider network.

Fundus Photography: What is it?

Before we dive into the basics of identifying unnecessary fundus photography, let's understand what it is. The fundus camera captures images of the eye's critical components—the retina, optic nerve head, macula, retinal blood vessels, choroid, and vitreous. Fundus photography plays an important role in detecting and screening various causes of treatable and preventable eye diseases.[1]

Defining Code: Fundus Photography and 92250

Now that we've set the stage let's explore the code that describes fundus photography - CPT code 92250 (Fundus Photography with interpretation and report). This code is the key to billing for this service. It's crucial to note that CPT 92250 encompasses one or more images captured with the fundus camera, whether or not filters are used.[2]

CPT 92250 is classified as bilateral, so the reimbursement covers both eyes. The 2020 national Medicare Physician Fee Schedule allowable stands at $45.83. Within this total, the technical component is $23.82, and the professional component (interpretation) is valued at $22.01. These figures may undergo adjustments based on local wage indices. Various other payers establish their own rates, which could notably vary from Medicare's officially published fee schedule. Fundus photography is subject to Medicare's Multiple Procedure Payment Reduction (MPPR), which results in a reduction in the allowable for the technical component when more than one test is conducted on the same day, with the lesser-valued test being affected.[3]

Is Fundus Photography Bundled with Other Services?

Per Medicare's National Correct Coding Initiative (NCCI), the codes for extended ophthalmoscopy, 92201 and 92202, are combined with fundus photography and cannot be separated under any circumstances. Similarly, the remote screening retinal test, 92227, is bundled with 92250 and cannot be unbundled. The technician exam 99211 is also bundled with 92250, as is the case with most tests. Additionally, code 92250 is mutually exclusive with scanning computerized ophthalmic diagnostic imaging of the posterior segment (92133, 92134).[3]

Identifying Medically Unnecessary Fundus Photography

Now, let's discuss how to identify medically unnecessary fundus photography within your provider network. Billing for an unusually high number of tests per eye for a significantly high percentage of beneficiaries could be a red flag. This might indicate that providers are billing for services that lack medical necessity. Below are some things I have learned when identifying alleged misuse of this coded service.

• A high number of fundus photography exams per beneficiary annually: If providers are billing for an exceptionally high number of fundus photography exams for a significantly large percentage of beneficiaries, it raises concerns. This could potentially indicate that these services lack medical justification.
• A high number of eye exams routinely billed with fundus photography services: If a majority of patients are receiving fundus photography services with their eye exams, this also could raise some red flags.

How much is too much you say?

To establish a threshold for identifying excessive billing of fundus photography, we turn to the Department of Health and Human Services Office of Inspector General. Their study on overutilization rates with fundus photography revealed trends that might suggest inappropriate billing practices. They propose a threshold of billing fundus photography as two exams per eye annually.[4]

In their extensive study, the Department of Health and Human Services Office of Inspector General identified approximately 2 million beneficiaries who underwent fundus photography exams in 2012. They then employed the Tukey methodology to pinpoint providers who billed for more than three fundus photography exams per eye annually for an unusually high percentage of their beneficiaries receiving these exams in 2012. These parameters resulted in the identification of around 10,393 providers.[4]

Wrap Up

In the world of healthcare billing, thoroughness is important here. Avoid hasty judgments solely based on patterns; instead, conduct a comprehensive investigation. This entails researching payer guidelines/policies, clinical review of patient records, and cross-referencing with industry standards. Healthcare data mining and analysis exceeds mere number crunching; it's important for transparency and ethical practice.

#HealthcareBilling #FundusPhotography #MedicallyUnnecessaryBilling #PatientWelfare #EthicalBilling

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[1] Fundus Camera - StatPearls - NCBI Bookshelf (nih.gov)

[2] Fundus Photography Coding Story Doesn't End at 92250 : Diagnostics (aapc.com)

[3] Ophthalmology Management - Coding and Reimbursement: Fundus photography billing

[4] Microsoft Word - Ophthalmology QB 9-2 (hhs.gov)