Currently, the Centers for Medicare & Medicaid Services (CMS) allows for one ocular examination a year for patients with diabetes without ocular complications. If ocular complications from diabetes are found, more frequent evaluations and other special testing may be medically necessary.
|PQRI for DR
Several Medicare Physician Quality Reporting Initiative (PQRI) codes are applicable for patients with diabetes. For patients 18 to 75 years old with or without diabetes, the 2022F quality data code (QDC) is appropriate. If diabetic retinopathy is found in a patient over 18 years old, use 2021F QDC. For the retinopathy report written to the primary care physician, use 5010F and G8397. In the event a report was not sent, attach G8398 to the claim. For more details, review the PQRI guidelines posted on the American Optometric Association website ( www.aoa.org/x7990.xml).
• Fundus photographs (92250). These can be obtained to monitor any ocular diabetic changes. When coding fundus photography, be sure to document a required “interpretation and report” (I&R) for this procedure. The I&R should be written in a separate section of the exam form or in a separate report. In addition, you’re also required to document the retinal findings in the usual area of the examination form. Fundus photography requires a written order, which is typically noted under the treatment plan section of the chart.
Some Medicare carriers allow fundus photography for the diagnosis of diabetes even without findings of ocular complications. But, some carriers limit this procedure when no changes can be documented. Refer to your carrier’s specific guidelines to ensure you’re meeting the fundus photography requirements.
• Gonioscopy (92020). This procedure may be used for patients with diabetes when you suspect anterior angle neovascularization. Gonioscopy may or may not be appropriate for all patients with diabetes. Documentation of medical necessity is important to justify this procedure. Again, understand your Medicare carrier’s rules for this procedure.
• Scanning computerized ophthalmic diagnostic imaging (92135). Macular edema may be more common than once thought. So, the use of scanning lasers to detect subclinical or early macular edema may be clinically appropriate. This procedure is a unilateral procedure; bill it per eye using the -RT and -LT modifiers. Again, each carrier may handle claims for this procedure differently.
If any question exists about the coverage of a procedure, ask the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN) prior to performing the procedure (www.cms.hhs.gov/BNI/02_ABN.asp). When an ABN is used, the procedure is billed using the -GA modifier to indicate the provider expects denial and the ABN is on file. Once the procedure is denied, the provider is allowed to collect the fees for the procedure from the patient.
Every eye doctor should send a report back to the primary physician(s) caring for the patient’s diabetic condition, even without the presence of ocular complications. These physicians need these reports to meet their care requirements. Also, writing reports to primary care and specialty physicians is a excellent tool to inform the general medical community of optometry’s role in the health care arena.
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