Do you know that fundus photography is one of the most performed services in eye care practices? In fact, data tells us that fundus photography is associated with nearly 10% of all office visits billed by ophthalmologists. This number goes up to 15% for optometrists. This also means that fundus photography is a major revenue source for ophthalmology practices.
So, getting claim denials for this procedure can be fatal to the revenue cycle. The service is usually billed via CPT code 92250. That is why we have put together this detailed guide. We will explain what this code is, the modifiers that you can use with it, and essential billing guidelines. So, let’s start.
CPT Code 92250 – Description
CPT code 92250 is defined as:
“Fundus photography with interpretation and report.”
92250 is an ophthalmology diagnostic code. It covers the imaging of the posterior segment of the eye, specifically the retina, optic disc, macula, and posterior pole. During the procedure, the physician uses a special camera, called a Fundus camera, to take detailed images of the interior surface. This imaging helps physicians diagnose and treat various diseases like retinopathy and glaucoma.
An important point to note here is that CPT code 92250 is a bilateral code. This means that a single instance of this code includes the reimbursement for both eyes. So, you should only bill CPT 92250 once per session, regardless of whether one or both eyes were photographed.
However, if only one eye was photographed, you can use modifier 52 to indicate the reduced service.
Also, for 92250 to be valid, it must have three important elements:
- Image acquisition
- Physician’s interpretation of those images
- Written report
Additionally, you should note that 92250 is only used to capture images. It does not involve gathering any quantitative data.
Scenarios Where CPT Code 92250 is Applicable
To give you an idea of how to use CPT code 92250 practically, let’s look at a couple of real-world scenarios in which this code is applicable.
Diabetic Retinopathy
Suppose a patient with a known history of type 2 diabetes visits an ophthalmologist. He reports blurred vision and progressive difficulty seeing fine details. Upon examination, the physician notes early-stage retinal changes consistent with diabetic retinopathy. To document the extent of retinal damage and establish an appropriate treatment plan, the physician orders fundus photography of both eyes.
The physician then reviews the photographs, documents the clinical findings, and produces a written interpretation report. In this case, the billing department can use CPT code 92250 to bill the fundus photography service.
Suspected Glaucomatous Progression
For our next scenario, suppose a patient has chronically elevated intraocular pressure. He is getting treatment and has come for a follow-up visit. The physician has already reviewed prior visual field tests and suspects progressive optic nerve damage. To document any structural changes in the optic nerve head and retinal nerve fiber layer (in 2D) that may indicate glaucomatous progression, the physician performs fundus photography.
The images are captured, reviewed in clinical context, and a detailed interpretive report is recorded in the patient’s chart. Like the first scenario, the entire procedure can be billed via CPT code 92250.
Applicable Modifiers for CPT Code 92250
The following modifiers are frequently used with CPT code 92250:
| Modifier | Short Description | Usage |
|---|---|---|
| 26 | Professional Component | Use when billing only for the physician’s interpretation and report. |
| 52 | Reduced Services | Append modifier 52 when fundus photography is performed on one eye instead of both, or there is a significant reduction in the overall process. |
| LT | Left Eye | Use when the procedure is performed on the left eye only. |
| RT | Right Eye | Use when the procedure is performed on the right eye only. |
| TC | Technical Component | Use when billing only for the technical aspects of the procedure, such as image acquisition, equipment use, and technician costs. |
Note: Code 92250 is inherently bilateral. So, don’t append modifier 50 if both eyes are imaged.
Also, understand that the use of modifiers LT and RT is subject to the payer’s policy. Medicare advises against using the RT and LT modifiers on separate line items. However, some commercial payers advise using the laterality modifiers for added specificity when only one eye is photographed. In this case, the coding will be 92250-52-LT or 92250-52-RT.
CPT Code 92250 – Billing & Reimbursement Guidelines
The following are some vital points to consider while filing claims for CPT code 92250:
Provide Detailed Documentation
Like all CPT codes, detailed documentation is important for 92250 as well. Your medical record must clearly support the medical necessity of the service and include the following:
- A clear diagnosis linked to a valid ICD-10-CM code.
- The type of fundus camera used.
- A written narrative confirming that the physician reviewed the images in a clinically meaningful way.
- Physical examination results that support the need for imaging.
Know the NCCI Edits and Bundling Restrictions
CPT 92250 is mutually exclusive from scanning computerized ophthalmic diagnostic imaging codes 92133 and 92134. In most cases, you can only bill one of these codes per session. However, with valid reasons, this rule can be bypassed.
Be Mindful of the Frequency Limitations
CPT code 92250 is subject to frequency limits set by individual Medicare Administrative Contractor (MAC) jurisdictions. According to guidelines published by the American Academy of Ophthalmology (AAO), fundus photography is generally considered medically necessary no more than twice per year under Medicare.
Check the Medicare Reimbursement Rate
The reimbursement rate for code 92250 varies for each payer and MAC locality. However, Medicare’s national average reimbursement amount in both facility and non-facility settings is $37.07.
Medicare reimburses 92250’s professional component (with modifier 26) at $20.37 and the technical component (with modifier TC) at $16.70.
You can check the exact amount for your MAC locality via the PFS Lookup Tool.
Wrapping Up
We have reached the end of this guide. Before concluding, let’s quickly recap the essential points:
- CPT code 92250 is used to bill fundus photography.
- For proper reimbursement, your documentation must clearly establish medical necessity and include a detailed physician interpretation and report.
- You should also append the appropriate modifiers when necessary.
However, even with all the guidelines, medical billing can be frustrating. If you are facing frequent denials or want to offload the complexity of ophthalmology coding, consider partnering with experienced specialists. Many companies, like MediBillMD, offer dedicated ophthalmology billing services that can help your practice maximize reimbursements.
