Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-04, Medicare Claims Manual, Chapter 12:

40.1.A. Global surgery period

Abstract:

Fundus photography
Fundus photography involves the use of a retinal camera to document abnormalities of the retina and disease processes affecting the eye, in order to follow the progress of such disease. The test must be used in the medical decision making for the patient.

Extended ophthalmoscopy
Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy. The examination must be used in the medical decision making for the patient.

Indications:

Fundus photography
Fundus photography may be indicated to document abnormalities of disease processes affecting the eye, or to follow the progress of such disease.

In order to document a disease process or follow the progress of a disease, photographs and an interpretation and report of the test may be necessary. Photographs and an interpretation and report of the test may also be necessary to plan treatment for a disease process.

Fundus photography may be used for the diagnosis of conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, glaucoma, multiple sclerosis or other central nervous system anomalies.

Fundus photography may be indicated for examination of the retina in diabetic patients, in whom symptoms of visual disturbances may be present and in whom retinal examination may be unremarkable or normal.

Extended ophthalmoscopy:

Extended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy.

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions:

• Malignant neoplasm of the retina or choroid.
  
  
• Retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing.
  
  
• Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration.
  
  
• Retinal detachment with or without retinal defect. The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as "a curtain came down over my eyes."
  
  
• Symptoms suggestive of retinal defect (ex: flashes and/or floaters).
  
  
• Retinal defects without retinal detachment.
  
  
• Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation.
  
  
• Experienced sudden visual loss or transient visual loss.
  
  
• Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment.
  
  
• Sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye.
  
  
• Sustained a blunt injury to the eye or pariorbita.
  
  
• Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment). Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders.
  
  
• Posterior scleritis. Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field.
  
  
• Vogt-Koyanagi syndrome. A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea.
  
  
• Degenerative disorders of the globe.
  
  
• Retinoschisis and retinal cysts. Patients may complain of light flashes and floaters.
  
  
• Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision.
  
  
• Glaucoma or is a glaucoma suspect. This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve.
  
  
• Systemic disorders which may be associated with retinal pathology.
  
  
• High axial length myopia
  
  
• Retinal edema
  
  
• Metamorphopsia
  
  
• High-risk medication for retinopathy or optic neuropathy.
  
  
• Choroidal nevus being evaluated for malignant transformation.
  
  
• Macular degeneration

Limitations:  

If the study is performed as a screening service, it is not covered by Medicare.

Fundus photography

• All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary.
• Fundus photography are bilateral services on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee.
• Fundus photography is not a substitute for an annual dilated examination by a qualified professional (e.g., in diabetic patients). Fundus photographs taken by a non-eye professional and sent (transtelephonically, via internet, or by other means) to a qualified professional for interpretation are covered for the monitoring and management of active retinal disease. The interpretation of tests done with remote imaging must be performed by a physician or qualified non-physician practitioner.
• Remote imaging for detection of retinal disease is considered screening and will be denied as non-covered.
• Provision of fundus photography, by providers other than ophthalmologists or optometrists, as a screening test to facilitate referral to a specialist is contrary to requirements for testing as codified in 42CFR 410.32, and is therefore not covered. Furthermore, the ordering/performance of fundus photography by eye specialists prior to a face-to-face encounter is similarly not covered or reimbursable.

Extended ophthalmoscopy:

• Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary.
• General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, but these should still be documented in the patient's medical record.
• If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated in the attached Appendix A, the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service.
• Extended ophthalmoscopy performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed.
• If the medical record does not include the interpretation and report, the extended ophthalmoscopy will be denied as not medically necessary.
• Extended ophthalmoscopy will be denied as not medically necessary when it is done in lieu of routine ophthalmoscopy unless the indication for this more extensive examination is documented in the medical record.
• When other ophthalmological tests (e.g., fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.

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This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Fundus photography

Bakri SJ, Sculley L, Sing AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13.
http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Mayfield J. Who cares about the quality of diabetes care? Almost everyone! Clinical Diabetes. 1998;16(4). http://journal.diabetes.org/clinicaldiabetes/v16n41998/Mayfield.htm. Accessed July 21, 2006.

National Guideline Clearinghouse. Age-related macular degeneration. Limited revision. www.guideline.gov. Accessed July 21, 2006.

National Guideline Clearinghouse. Care of the patient with diabetes mellitus. 3rd edition. www.guideline.gov. Accessed July 21, 2006.

National Guideline Clearinghouse. Care of the patient with retinal detachment and related peripheral vitreoretinal disease. www.guideline.gov. Accessed July 21, 2006.

Other carrier policy (Empire Medicare Services [effective 06/01/1996] L682). http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed July 21, 2006.

Other carrier policy (Empire Medicare Services [effective 10/01/2005] L3634 R5). http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed July 21, 2006.

Other carrier policy (First Coast Service Options [effective 10/30/2006] L18148 R1). http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed December 8, 2006.

Singh RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195-208. http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Extended ophthalmoscopy

Carrier Medical Director, BCBS, Kansas.

Comments from American Academy of Ophthalmology.

Comments from New York State Ophthalmology CAC representative.

Comments from New York State Optometric Association.

Comments from practicing ophthalmologists.

Comments from retinal consultants.

Consultants in Optometry (New Jersey).

CPT editorial staff.

Duane's Clinical Ophthalmology, J. B. Lippincott Co.; 1994.

Essentials of Ophthalmology, Editors Bartley and Liesegang, J.B. Lippincott Co.;1992.

Focus panel of invited ophthalmologists/optometrists convened October 11, 2000 in New York.

Guyer DR, Yannuzzi LA, Chang, S, Shields JA, Green WR. Retina vitreous macula, clinical examination of the posterior segment of the eye. W.B. Saunders Company; 1999:21-28.

HCFA Regional Office reimbursement specialist.

Jones WL, Reidy RW. Atlas of the peripheral ocular fundus. Butterworth Publishers; 1985:1-4.

McPhee S, Papadakis M, Tierney L. Current medical diagnosis and treatment. Stanford: Appleton and Lange; 1996.

Newell F. Ophthalmology-principles and concepts. St. Louis: Mosby; 1992.

Other Carrier Policies:
First Coast Service Options, Inc. - Florida – Database # L6030 (12/18/1995)
Trailblazer Health Enterprises, LLC – Texas – Database # L8867 (11/05/1996)

Additional sources used in reconsideration request for September 1, 2009 revision:

Bresnick GH, Mukaamel DB, Dickinson JC, Cole DR. A screening approach to the surveillance of patients with diabetes for the presence of vision-threatening retinopathy. Ophthalmology. 2000;107:19-24.

Hutchinson A, McIntosh A, Peters J, et al. Effectiveness of screening and monitoring tests for diabetic retinopathy – a systemic review. Diabetes Medicine. 2000;17:495-506.

Personal communications, CMS Coverage and Analysis Group, Marcel Salive, MD, Louis Jacques, MD and Ross Brechner, MD.

Williams GA, Scott IU, Haller JA, et al. Single-field fundus photography for diabetic retinopathy screening. Ophthalmology. 2004;111:1055-1062.

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• Fundus
• eyes
• retina