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MP 9.03.99  Fundus Photography

Medical Policy    
Section
Miscellaneous Policies
 
Original Policy Date
10/2012
Last Review Status/Date
Created with literature search/10:2012
Issue
10:2012
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

The retinal fundus is the interior lining of the eyeball and is the area that can be seen through the pupil during an eye examination. 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.

Fundus photography is used to document abnormalities of the eye or disease progression and may be used for conditions such as macular degeneration, glaucoma, neoplasms of the retina and choroid (benign and malignant), retinal hemorrhages, ischemia, retinal detachment, choroid disturbances, multiple sclerosis, and other central nervous system abnormalities, and diabetic retinopathy. It may also be used for assessment of recently performed retinal laser surgery.

Fundus photographs are only considered medically necessary where the results may influence the management of the patient.  In general, fundus photography is performed to evaluate abnormalities in the fundus, follow the progress of a disease, plan the treatment for a disease, and assess the therapeutic effect of recent surgery (e.g., photocoagulation).  Fundus photographs are not medically necessary simply to document the existence of a condition.  However, photographs may be medically necessary to establish a baseline to judge later whether a disease is progressive.

Sequential series of photographs are considered medically necessary 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.  Repeat fundus photography may be medically necessary when an examination of the fundus reveals that the disease or condition of the fundus has progressed, such that prior fundus photographs no longer depict the pathology at the present time.  Repeated fundus photographs of the same disease or condition, without any meaningful change, are not considered medically necessary.  In addition to disease progression, repeat fundus photographs may be necessary if there is a new disease affecting the fundus, or for planning for additional surgical treatment.  Routine images that do influence treatment are not considered medically necessary.  When performed concurrently, the medical necessity of fundus photography and scanning computerized diagnostic imaging of the posterior segment should be documented in the medical record.

Documentation in the patient's medical record should include a current, pertinent history and physical examination, and progress notes describing and supporting the covered indication for fundus photography, and pertinent prior diagnostic testing and completed report(s), including, when appropriate, previous fundus photographs.  Fundus photographs should be properly labeled as to which eye they represent, the date they were taken, and the date they were reviewed.  The medical records should document the findings of the fundus photography, including a description of changes from prior fundus photographs (if any), and an interpretation of those findings, and the implications of the photographic evidence, including whether any changes in the treatment plan will be instituted as a result of the photographs.  Fundus photographs without an interpretation are considered not medically necessary.  All documentation must be maintained in the member’s medical record.  The record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)), as well as the physician or non-physician practitioner responsible for and providing the care of the patient.

When indicated for glaucoma, the interpretation of the fundus photographs should include a report of the vertical and horizontal cup/disc ratio based upon vessel pattern and/or coloration, the presence or absence of diffuse or focal pallor, the presence or absence of asymmetry, and the presence or absence of progression regarding any of the above parameters.  If the fundus photographs include red-free images, commentary on the status of the retinal nerve fiber layer should accompany the images.

The American Academy of Ophthalmology (Marmor et al, 2011) does not recommend the use of fundus photography for screening of chloroquine and hydroxychloroquine retinopathy.  It is not sensitive enough for screening because recognizable bull's-eye retinopathy signifies relatively advanced chloroquine or hydroxychloroquine toxicity.

Salcone et al (2010) stated that retinopathy of prematurity (ROP) is a vision-threatening vaso-proliferative condition of premature infants worldwide.  As survival rates of younger and smaller infants improve, more babies are at risk for the development of ROP and blindness.  Meanwhile, fewer ophthalmologists are available for bedside indirect ophthalmoscopy screening examinations.  Remote digital imaging is a promising method with which to identify those infants with treatment-requiring or referral-warranted ROP quickly and accurately, and may help circumvent issues regarding the limited availability of ROP screening providers.  The Retcam imaging system is the most common system for fundus photography, with which high-quality photographs can be obtained by trained non-physician personnel and evaluated by a remote expert.  It has been shown to have high reliability and accuracy in detecting referral-warranted ROP, particularly at later post-menstrual ages.  Additionally, the method is generally well-received by parents and is highly cost-effective.

An UpToDate review on "Retinopathy of prematurity" (Paysse, 2012) does not mention the use of digital imaging or fundus photography.  It states that "screening evaluation consists of a comprehensive eye examination performed by an ophthalmologist with expertise in neonatal disorders"


Policy

Blue Cross of Idaho considers fundus photography medically necessary when the criteria and guidelines below are met.  Fundus photography may be considered medically necessary when clinically indicated to document a clinically relevant condition that is subject to change in extent, appearance or size, and where such change would directly affect the management.  Photographs are medically necessary to establish a baseline to judge later if a disease is progressive.

In general, fundus photography may be considered medically necessary if performed to:

• evaluate abnormalities in the fundus,

• follow the progress of a disease,

• plan the treatment for a disease,

• assess the therapeutic effect of recent surgery (e.g., photocoagulation).

Examples are as follows:

A patient presents with a history of dry age related maculopathy. It is not medically necessary for fundus photography to document its existence. However, fundus photography may be necessary to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy. In four to six months, the baseline photograph can be compared to the clinical appearance of the current diabetic retinal edema to see if it is progressing to clinically significant diabetic macular edema. This information can be used to decide clinical management. The intent of this scenario is to point out how in the former example there is not a therapeutic decision being made; in the latter there is. Fundus photography should aid in making a clinical decision.

Fundus photography is not medically necessary simply to document the existence of a condition. Fundus photography is also  considered not medically necessary for routine screening.


Policy Guidelines

92250

CPT Code 92250 is a bilateral procedure and should be billed only once.


Rationale

Blue Cross of Idaho may request medical records for determination of medical necessity. When medical records are  requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

References:

 

    1. Novitas Solutions, Inc   Fundus photography. Medicare Local Coverage Determination (LCD) L27498. Medicare Administrative Contractor (MAC) Parts A and B,  April 2, 2012.
    2. American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
    3. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
    4. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
    5. American Academy of Ophthalmology (AAO). Primary angle closure. Preferred Practice Pattern. San Francisco, CA: AAO; 2010.
    6. American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
    7. American Academy of Ophthalmology. Posterior vitreous detachment, retinal breaks, and lattice degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2008.
    8. Wong D. The fundus camera. In: Duane's Clinical Ophthalmology. Vol. 1. Rev. ed. W Tasman, EA Jaeger, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 1999; Ch. 61:1-14.
    9. Chang DF. Ophthalmologic examination. In: General Ophthalmology. 15th ed. D Vaughan, T Asbury, P Riordan-Eva, eds. Stamford, CT: Appleton & Lange; 1999; Ch. 2:27-56.
    10. Mardin CY, Junemann AG. The diagnostic value of optic nerve imaging in early glaucoma. Curr Opin Ophthalmol. 2001;12(2):100-104.
    11. Shiba T, Yamamoto T, Seki U, et al. Screening and follow-up of diabetic retinopathy using a new mosaic 9-field fundus photography system. Diabetes Res Clin Pract. 2002;55(1):49-59.
    12. Larsen M, Godt J, Larsen N, et al. Automated detection of fundus photographic red lesions in diabetic retinopathy. Invest Ophthalmol Vis Sci. 2003;44(2):761-766.
    13. Williams GA, Scott IU, Haller JA, et al. Single-field fundus photography for diabetic retinopathy screening: A report by the American Academy of Ophthalmology. Ophthalmology. 2004;111(5):1055-1062.
    14. Marmor MF, Carr RE, Easterbrook M, Farjo AA, Mieler WF; American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: A report by the American Academy of Ophthalmology. Ophthalmology 2002;109(7):1377-1382.
    15. Davis MD, Bressler SB, Aiello LP, et al; Diabetic Retinopathy Clinical Research Network Study Group. Comparison of time-domain OCT and fundus photographic assessments of retinal thickening in eyes with diabetic macular edema. Invest Ophthalmol Vis Sci. 2008;49(5):1745-1752.
    16. Polak BC, Hartstra WW, Ringens PJ, Scholten RJ. Revised guideline 'Diabetic retinopathy: Screening, diagnosis and treatment'. Ned Tijdschr Geneeskd. 2008;152(44):2406-2413.
    17. American Diabetes Association. Position statement: Standards of medical care in diabetes - 2010. Diabetes Care. 2010;33(Suppl. 1):S11-S61.
    18. Jain N, Farsiu S, Khanifar AA, et al. Quantitative comparison of drusen segmented on SD-OCT versus drusen delineated on color fundus photographs. Invest Ophthalmol Vis Sci. 2010;51(10):4875-4883.
    19. Marmor MF, Kellner U, Lai TY, et al; American Academy of Ophthalmology. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118(2):415-422.
    20. Salcone EM, Johnston S, VanderVeen D. Review of the use of digital imaging in retinopathy of prematurity screening. Semin Ophthalmol. 2010;25(5-6):214-217.
    21. American Diabetes Association (ADA). Standards of medical care in diabetes. VI. Prevention and management of diabetes complications. Diabetes Care 2011;34(Suppl 1):S27-S38.
    22. Paysse EA. Retinopathy of prematurity. UpToDate [online serial]. Waltham, MAL UpToDate; reviewed March 2012.

 

Codes

Number

Description

CPT  92250 Fundus photography with interpretation and report
ICD-9 Diagnosis  042 Human immunodfeficiency virus (HIV) disease
  084.0-084.9 Malaria
  094.85 Syphilitic retrobulbar neuritis
  115.02 Infection by Histoplasma capsulatum, retinitis
  115.12 Infection by Histoplasma duboisil, retinitis
  115.90-115.99 Histoplasmosis, unspecified, retinitis
  130.1 Conjuctivitis due to toxoplasmosis
  130.2 Choroirtinitis due to toxoplasmosis
  190.0-190.9 Malignant neoplasm of eye
  198.4 Secondary malignant neoplasm of other parts of nervous system
  224.0 Benign neoplasm of eyeball, except conjuctiva, 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 if uncertain behavior of other specified sites
  238.9 Neoplasm of uncertain behavior unspecified
  239.81 Neoplasm of unspecified nature of retina and choroid
  249.00-250.93 Diabetes mellitus
  270.2 Other disturbances of aromatic amino-acid metabolism
  282.60-282.69 Sickle-cell disease
  340 Multiple Sclerosis
  348.2 Benign intracranial hypertension  [pseudotumor cerebi]
  360.00-360.89 Disorders of the globe
  361.00-361.9 Retinal detachment and defects
  362.01-362.9 Other retinal disorders
  363.00-363.9 Choroideretinal inflammation, scars, and other disorders of choroid
  364.22 Glaucomatocyclitic crises
  364.24 Vogt-Koyanagi syndrome
  364.3 Unspecified iridocyclitis
  365.00-365.9 Glaucoma
  368.51-368.59 Color vision deficiencies
  377.00-377.9 Disorders of optic nerve and visual pathways
  379.00-379.29 Disorders of vitreous body
  379.32 Sublaxation of lens
  379.34 Posterior dislocation of lens
  695.4 Lupus erythematosus
  710.0 Systemic lupus erythematosus
  714.0-714.9 Rheumatoid arthritis and other imflammatory polyarthropathies
  743.51-743.59 Congenital anomalies of posterior segment
  759.5 Tuberous sclerosis
  759.6 Other hamartoses, not elsewhere classified
  759.81-759.89 Other specified anomalies
  771.0 Congenital rubella
  794.11 Abnormal retinal function studies
  794.12 Abnormal elector-oculogram (EOG)
  794.13 Abnormal visually evoked potential
  794.14 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 [hydroxychloroquine toxicity]
  961.5 Poisoning by other antiprozotoal drugs
  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 woth high-risk medications, not elsewhere classified
ICD-10-CM (effective 10/1/13) B20 Human immunodfeficiency virus (HIV) disease
ICD-10-PCS (effective 10/1/13)   ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure.


Policy History

Date Action Reason
10/2012 Policy added to Other;Vision sub-section New policy created with literature review; considered med nec for specific diagnoses