retinal cameras

Photographing the Fundus

Here's a look at the general indications for fundus photography and the coding necessary to obtain reimbursement for this important service.

DEEPAK GUPTA, O.D., Stamford, Conn.

The National Eye Institute estimates that more than five million people in the United States have diabetic retinopathy. In addition, more than 10 million Americans have age-related macular degeneration (AMD), according to the American Macular Degeneration Foundation. Further, more than three million Americans have glaucoma, but only half are aware of it, says the Glaucoma Research Foundation. The good news: The various retinal cameras currently available on the market provide clear, high-resolution images of the fundus, assisting you, after patient-dilated indirect ophthalmoscope, in early diagnosis and management of these conditions, so you can prevent vision loss and enable your patients to maintain their quality of life. (See "Retinal Camera Manufacturers".)

Here, I discuss the general clinical applications for fundus photography and the coding necessary to obtain reimbursement for this service.

General indications

You should employ retinal photography for the following ocular conditions:

► Diabetic retinopathy. Fundus photodocumentation can help you monitor early signs of the disease, such as retinal microaneurysms. Though these can be difficult to see, with digital and traditional stereo-fundus photography, you can usually increase the camera's magnification to enhance your view. These images can be a great asset in grading the degree of retinopathy, whether non-proliferative, proliferative or associated with macular edema. Further, they can help you choose a course of action (i.e. continue monitoring the patient or referral to a retinal specialist for further evaluation).

For instance, the standard of care for a patient displaying scattered microaneurysms, which appear to demonstrate some level of progression when compared with a previous photograph, is to refer the patient to a retinal specialist for a consult just to be on the safe side.

Fundus photography is also beneficial for monitoring the post-treatment status of diabetic patients who undergo pan-retinal laser photocoagulation therapy. Proliferative diabetic retinopathy patients usually undergo this treatment. Because proliferative diabetic retinopathy can continue progressing even after this therapy, it's essential you monitor the retina for any signs of disease progression, such as leaking blood vessels. This will enable you to decide whether additional laser therapy is warranted. Also, because this treatment can result in adverse events, such as vitreous hemorrhage, neovascular glaucoma and retinal detachment, fundus photography enables you to monitor patients for these possible outcomes.¹

► AMD. You should obtain photodocumentation of the earliest changes associated with this disease, such as drusen or pigmentary degeneration of the retina, as doing so enables you to track the progression of the disease and prevent vision loss. I've found retinal photography particularly useful when prescribing treatment to my AMD patients because the fundus photos allow me to track the effect, if any, eye supplementation (lutein, zeaxanthin, etc.) has on the progression of the disease.

This fundus photograph demonstrates an increased cup-to-disc ratio.

The frequency of retinal photography for an AMD patient depends on his family/personal history and clinical findings. For instance, the standard of care for a patient who has a family history of AMD, soft confluent drusen and granular pigmentary degeneration warrants annual fundus photography. I take serial, yearly photographs on all my AMD patients, though this doesn't substitute for other devices, such as Ocular Coherence Tomography/Scanning Laser Ophthalmoscope, which you can do in addition to photography.

► Glaucoma. Successful management of glaucoma patients depends on your ability to recognize optic-nerve change, such as increased cup-to-disc ratio, through time. This is why Glaucoma is the most common indication for fundus photography. In fact, the American Optometric Association's (AOA) Clinical Practice Guidelines cite stereo photography as the preferred method of documenting and monitoring the optic nerve in any patient suspected of having glaucoma. Overlaying various photos of the fundus through time allows you to scrutinize the retina for any subtle changes, aiding in your decision on management.

The standard of care: Dilate glaucoma patients and those at high risk for developing the disease, such as Hispanic and black patients, every year using a diagnostic lens to obtain a high-definition view of the optic nerve. Then, perform stereo-retinal photography as a means of complimenting your findings.

► Choroidal nevus. Although, the percentage of patients who demonstrate malignant transformation of pigmented choroidal lesions is exceedingly rare, it's imperative you monitor these "ocular freckles" for changes, which may indicate malignancy.² These changes include orange coloration, thickness of 2mm or more and leaking fluid.³

The standard of care: To facilitate a fast diagnosis of a malignant choroidal nevus, obtain baseline fundus photographs of all choroidal nevi annually. If, however, any of the nevi appear orange or thicker than previously seen, follow the patient more closely.²

Here's a fundus photo of a patient who has AMD.

► Peripheral retinal lesions. Many currently available retinal cameras offer adequate views of peripheral retinal lesions for photodocumentation. You can utilize these images as baseline data for atrophic holes, lattice degeneration, retinal tears, retinoschisis and retinal detachment.

The standard of care: To obtain a quality photo of the periphery, maximally dilate (two or three sets of drops) the patient, and set the camera to compensate for peripherally induced astigmatism.

► Papilledema, optic neuritis or anterior optic neuropathy. If your patient presents with signs of any of these ocular anomalies upon dilated indirect ophthalmoscopy, document the status of the optic nerve via fundus photography, and immediately refer him to the appropriate healthcare practitioner for a medical workup. This is because these conditions are associated with serious systemic disease.

For instance, if a patient presents with small hemorrhages of the nerve fiber layer or disc hyperemia, he may have papilledema. Papilledema is caused by tumors or space-occupying lesions of the central nervous system, idiopathic intracranial hypertension, decreased cerebrospinal fluid resorption, obstruction of the ventricular system, cerebral edema/encephalitis and craniosynostosis.⁴ As a result, it's imperative you refer this patient to a neurologist, as doing so may very well save his life.

Coding basics

If you want a patient's health insurance to reimburse you for your services, perform fundus photography only when medically indicated — either as a baseline or to monitor disease progression. In most cases, health-insurance companies look for a specific clinical diagnosis to justify fundus photography.

An example: To obtain reimbursement for the use of a retinal camera on a patient suspected of having glaucoma, often, you must reveal to the health-insurance company that the patient presented with glaucoma-related risk factors, such as active cupping and elevated intraocular pressure. Do this by providing the health-insurance company with their required documentation to support the need for additional testing beyond the comprehensive eye exam.

In most cases, you'll perform fundus photography at the end of the comprehensive eye exam with the patient's pupils dilated. Through my own experience, I've discovered that health-insurance companies usually won't allow retinal photography on the same day as scanning computerized diagnostic imaging (Current Procedural Terminology [CPT] code 92135). Infrequently, a plan may not allow 92135 on the same day as visual field (VF) testing (CPT code 92083). This is the result of National Correct Coding Inititiative (NCCI) Edits and/or Local Carrier Determinations.

The standard code sets used in optometric practices are comprised of the International Classification of Diseases (ICD)-9 codes for diagnoses — the CPT codes for most procedures. Use CPT code 92250 for fundus photography. For many health-insurance companies, this code means the service rendered was binocular. Rarely, a plan requires a reduced services modifier (-52) and to bill half your usual fee in the rare case, in which you only obtain photographs of one eye, but this is not typical. I've discovered that you may use this CPT code in addition to other services, such as a comprehensive eye exam, for which you see the patient on that same day.

The CPT descriptions of documentation requirements for many ophthalmic diagnostic tests include the phrase, "… with interpretation and report." Once the appropriate individual has performed the test, you must document your interpretation of the results somewhere in the patient's medical record. This documentation may merely be a brief phrase indicating whether a test is "normal," "stable from a previous test" or "mild superior arcuate defect." If you've performed multiple fundus imaging tests, the patient's health-insurance company may require you to create a separate report for each test.

The interpretation should generally include a comment about the reliability of the test results (i.e., whether the patient was compliant and the quality of the photos), as well the impact the test results will have on the course of treatment (no treatment necessary, continue current medications, or add new medications). You can put this interpretation on a separate page from the examination record as part of the assessment plan list. You can even write it on the test result directly.

The most important factor for reimbursement is that you must use the results of any test or diagnostic procedure you order to help you diagnose and manage the disease. (See "Common Items Required For Reimbursement," above.)

Fundus photography allows you to provide the best care for your retinal-pathology patients, as it assists you in early diagnosis and management. Also, because a picture is worth a thousand words, it enables you to effectively communicate your findings with other healthcare providers, such as primary-care physicians and ophthalmologists, and instills medication-compliance in your patients. Finally, when you take the time to code properly, you'll receive reimbursement for this service, which helps grow your practice. OM

1. Dumitrache M, Anitescu M, Carstocea B. Laser treatment in diabetic retinopathy. Oftalmologia. 1995 Apr-Jun;39(2):159-69.
2. Singh AD, Kalyani P, Topham A. Estimating the risk of malignant transformation of a choroidal nevus. Ophthalmology. 2005 Oct;112(10):1784-9.
3. eyecancernetwork. Choroidal Nevus. www.eyecancer.com. (Accessed 4/2/08)
4. emedicine. Papilledema. Giovannini J. www.emedicine.com/OPH/topic187.htm (Accessed 4/2/08')

Dr. Gupta practices in Stamford, Conn. He's also clinical director of The Center for Keratoconus at Stamford Ophthalmology. E-mail him at Deegup4919@hotmail.com.