Dr. Wolfe shares a fundus photo of retinoschesis. He says there are important nuances to be aware of when billing for repeat fundus photos.
Medicare guidelines for repeat fundus photography
By Christopher Wolfe, OD, FAAO, Dipl. ABO
August 28, 2024
In the world of medical billing, particularly within ocular disease management, it’s not uncommon to encounter scenarios that challenge our established practices.
One such area that often raises questions is the appropriate billing for repeat fundus photography when monitoring stable conditions like choroidal nevi, glaucoma or macular degeneration.
Frequently Asked Question
How should we approach billing for repeat fundus photography when monitoring stable ocular conditions? Is it appropriate to bill for photos on an annual basis, or does Medicare’s guidance suggest otherwise?
Let your documentation tell the story.
The key to addressing this issue lies in ensuring that your billing practices are consistent with Medicare’s guidelines, which emphasize the necessity of medical justification for repeat imaging.
According to Medicare, repeat fundus photography is warranted if there is evidence of disease progression, the emergence of new disease, or the need to plan additional treatments, such as laser therapy. Simply repeating photos of an unchanged condition does not meet these criteria and, therefore, may not be billable.
The most critical factor in justifying repeat fundus photography is your clinical documentation. If, during an evaluation, you detect a potential change in the patient’s condition—such as a difference noted between a current ophthalmoscopic examination and a previous photo—this could justify the need for repeat imaging. Your documentation should clearly reflect this clinical judgment.
For example, you might document, “Likely change in diabetic retinopathy on ophthalmoscopic examination when compared to prior photo. Order photo to further evaluate for progression.” Such detailed documentation provides a clear rationale for the repeat imaging and can help protect your practice in the event of an audit.
Why Other Diagnostic Tests Are Different
When it comes to other diagnostic tests, such as visual field (VF), ganglion cell complex (GCC), fundus autofluorescence (FAF), or retinal nerve fiber layer (RNFL) imaging, these tests differ from fundus photography in several significant ways.
These tests provide quantitative and qualitative data that cannot be obtained through a standard clinical examination alone.
For instance, a visual field test quantitatively measures the patient’s field of vision, which is critical in diagnosing and managing conditions like glaucoma.
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Similarly, GCC, FAF and RNFL imaging offer detailed insights into the structural integrity of the retina and optic nerve, often detecting subtle changes that are not visible with ophthalmoscopy or fundus photography.
Because these tests deliver unique, objective data that directly influence clinical decision-making, they are often repeated according to specific guidelines, such as every six months or annually, depending on the condition being monitored.
Repeating these tests is generally considered medically necessary as they provide information essential for ongoing management and treatment of ocular diseases. The justification for these tests is more straightforward, as they offer insights that a standard exam cannot replicate.
Final Thoughts
While annual fundus photography has been a common practice for monitoring stable ocular conditions, Medicare’s guidelines underscore the importance of documenting medical necessity.
Repeat imaging should be reserved for situations where there is observable change or the development of new symptoms. Accurate and thorough documentation is essential to justify these decisions and ensure compliance with billing practices.
On the other hand, other diagnostic tests like VF, GCC, FAF and RNFL are inherently different because they offer crucial information that is not otherwise obtainable through regular exams. These tests are fundamental in the ongoing management of ocular diseases, making their repetition both justified and necessary when following clinical guidelines.
By staying diligent in our documentation and adhering to these guidelines, we can continue to provide exceptional care while safeguarding our practices against potential billing issues.
Christopher Wolfe, OD, FAAO, Dipl. ABO, is the founder of EyeCode Education and the owner of Exclusively Eyecare, a Vision Source practice in Omaha, Neb. To contact him: drmoskweli@gmail.com
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
