Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27498
LCD Title
Fundus Photography
Contractor’s Determination Number
L27498
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare 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 1862(a)(7). This section excludes routine physical examinations.
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.
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after 08/01/2008
Revision Ending Date
08/31/2008
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Fundus photography involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve. The resultant images may be either photographic or digital and become part of the patient’s permanent record. Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated.
A single series of photographs will be reimbursed where clinically indicated.
Sequential series of photographs will only be covered only if they document a clinically relevant condition that is subject to change in extent, appearance or size, and where such change would directly affect the management. Routine images to embellish the record, but a succession of which would not influence treatment, would not be reimbursed.
Some national organizations, including CMS, recommend that annual ophthalmoscopy (through a dilated pupil where not contraindicated) of diabetic patients asymptomatic for visual symptoms be a Standard of Care. This Contractor will not pay for annual fundal photography (whether conventional or digital) as a substitute for such annual examination by an eye care provider as defined by their scope of practice.
Coverage Topic
Diagnostic Tests and X-Rays
Coding Information
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
051X | Clinic-general classification |
076X | Treatment or observation room-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
92250 | FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
094.85 | SYPHILITIC RETROBULBAR NEURITIS |
115.02 | HISTOPLASMA CAPSULATUM RETINITIS |
HISTOPLASMOSIS UNSPECIFIED WITHOUT MANIFESTATION - HISTOPLASMOSIS UNSPECIFIED WITH OTHER MANIFESTATION | |
130.1 | CONJUNCTIVITIS DUE TO TOXOPLASMOSIS |
130.2 | CHORIORETINITIS DUE TO TOXOPLASMOSIS |
MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED | |
198.4 | SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM |
224.0 | BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID |
224.5 | BENIGN NEOPLASM OF RETINA |
224.6 | BENIGN NEOPLASM OF CHOROID |
225.1 | BENIGN NEOPLASM OF CRANIAL NERVES |
234.0 | CARCINOMA IN SITU OF EYE |
238.8 | NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES |
238.9 | NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED |
239.8 | NEOPLASM OF UNSPECIFIED NATURE OF OTHER SPECIFIED SITES |
DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED | |
270.2 | OTHER DISTURBANCES OF AROMATIC AMINO-ACID METABOLISM |
SICKLE-CELL DISEASE UNSPECIFIED - OTHER SICKLE-CELL DISEASE WITH CRISIS | |
340 | MULTIPLE SCLEROSIS |
PURULENT ENDOPHTHALMITIS UNSPECIFIED - VITREOUS ABSCESS | |
SYMPATHETIC UVEITIS - OTHER ENDOPHTHALMITIS | |
DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED - OTHER DEGENERATIVE DISORDERS OF GLOBE | |
HYPOTONY OF EYE UNSPECIFIED - FLAT ANTERIOR CHAMBER OF EYE | |
DEGENERATED GLOBE OR EYE UNSPECIFIED - LEUCOCORIA | |
FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY MAGNETIC IN OTHER OR MULTIPLE SITES | |
FOREIGN BODY INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY IN OTHER OR MULTIPLE SITES | |
360.81 | LUXATION OF GLOBE |
360.89 | OTHER DISORDERS OF GLOBE |
RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL | |
RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS | |
361.2 | SEROUS RETINAL DETACH |
RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH | |
361.81 | TRACTION DETACH OF RETINA |
361.89 | OTHER FORMS OF RETINAL DETACH |
361.9 | UNSPECIFIED RETINAL DETACH |
BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA | |
BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS | |
362.21 | RETROLENTAL FIBROPLASIA |
362.29 | OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY |
RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA | |
RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM | |
MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA | |
PERIPHERAL RETINAL DEGENERATION UNSPECIFIED - SECONDARY VITREORETINAL DEGENERATIONS | |
HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE | |
RETINAL HEMORRHAGE - RETINAL NERVE FIBER BUNDLE DEFECTS | |
362.89 | OTHER RETINAL DISORDERS |
362.9 | UNSPECIFIED RETINAL DISORDER |
FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL | |
DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY | |
CHORIORETINITIS UNSPECIFIED - HARADA'S DISEASE | |
CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA | |
CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID | |
HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL | |
CHOROIDAL HEMORRHAGE UNSPECIFIED - CHOROIDAL RUPTURE | |
CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH | |
363.8 | OTHER DISORDERS OF CHOROID |
363.9 | UNSPECIFIED DISORDER OF CHOROID |
364.22 | GLAUCOMATOCYCLITIC CRISES |
364.24 | VOGT-KOYANAGI SYNDROME |
364.3 | UNSPECIFIED IRIDOCYCLITIS |
PREGLAUCOMA UNSPECIFIED - OCULAR HYPERTENSION | |
OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA | |
PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA | |
365.31 | CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE |
365.32 | CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE |
GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES | |
PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS | |
GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA | |
HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA | |
365.9 | UNSPECIFIED GLAUCOMA |
PROTAN DEFECT - OTHER COLOR VISION DEFICIENCIES | |
PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME | |
OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY | |
DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA | |
OPTIC NEURITIS UNSPECIFIED - OTHER OPTIC NEURITIS | |
ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE | |
DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS | |
DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS - DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH INFLAMMATORY DISORDERS | |
DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS - CORTICAL BLINDNESS | |
377.9 | UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS |
379.00 | SCLERITIS UNSPECIFIED |
379.07 | POSTERIOR SCLERITIS |
379.11 | SCLERAL ECTASIA |
VITREOUS DEGENERATION - OTHER DISORDERS OF VITREOUS | |
379.32 | SUBLUXATION OF LENS |
379.34 | POSTERIOR DISLOCATION OF LENS |
695.4 | LUPUS ERYTHEMATOSUS |
710.0 | SYSTEMIC LUPUS ERYTHEMATOSUS |
RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY | |
VITREOUS ANOMALIES CONGENITAL - OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT | |
759.5 | TUBEROUS SCLEROSIS |
759.6 | OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED |
PRADER-WILLI SYNDROME - OTHER SPECIFIED CONGENITAL ANOMALIES | |
771.0 | CONGENITAL RUBELLA |
794.11 | NONSPECIFIC ABNORMAL RETINAL FUNCTION STUDIES |
794.12 | NONSPECIFIC ABNORMAL ELECTRO-OCULOGRAM (EOG) |
794.13 | NONSPECIFIC ABNORMAL VISUALLY EVOKED POTENTIAL |
794.14 | NONSPECIFIC ABNORMAL OCULOMOTOR STUDIES |
871.5 | PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY |
871.6 | PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY |
961.4 | POISONING BY ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA |
V58.65 | LONG-TERM (CURRENT) USE OF STEROIDS |
V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27498
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
08/01/2008 |
L27498 |
LCD effective 08/01/2008 for DC Part A, Maryland Part A, and Pennsylvania Part A. LCD is now effective for DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
05/23/2008 |
L27498 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D23 |
Original LCD posted for comment. |
Last Reviewed On
07/31/2008
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