Local Coverage Determination (LCD): Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (L33467) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Palmetto GBA A and B MAC 10111 - MAC A J - J Alabama Palmetto GBA A and B MAC 10211 - MAC A J - J Georgia Palmetto GBA A and B MAC 10311 - MAC A J - J Tennessee Palmetto GBA A and B and HHH MAC 11201 - MAC A J - M South Carolina Palmetto GBA A and B and HHH MAC 11202 - MAC B J - M South Carolina Palmetto GBA A and B and HHH MAC 11301 - MAC A J - M Virginia Palmetto GBA A and B and HHH MAC 11302 - MAC B J - M Virginia Palmetto GBA A and B and HHH MAC 11401 - MAC A J - M West Virginia Palmetto GBA A and B and HHH MAC 11402 - MAC B J - M West Virginia Palmetto GBA A and B and HHH MAC 11501 - MAC A J - M North Carolina Palmetto GBA A and B and HHH MAC 11502 - MAC B J - M North Carolina Back to Top LCD Information Document Information LCD ID Original Effective Date L33467 For services performed on or after 10/01/2015 Original ICD-9 LCD ID Revision Effective Date L32953 For services performed on or after 01/29/2018 Revision Ending Date LCD Title 02/25/2018 Ophthalmology: Extended Ophthalmoscopy and Fundus Photography Retirement Date N/A Proposed LCD in Comment Period N/A Notice Period Start Date N/A Source Proposed LCD N/A Notice Period End Date N/A AMA CPT / ADA CDT / AHA NUBC Copyright Statement Printed on 1/29/2018. Page 1 of 45 CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are 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, §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. Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. 42 CFR §410.32(a) 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). 42 CFR §411.15(k)(1) indicates coverage exlusion for any services that are not reasonable and necessary for the following purpose: For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §280.1 Glaucoma Screening CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §80.6 Intraocular Photography CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §40.1.A Components of a Global Surgical Package CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 18, §§70-70.5 Glaucoma Screening Services Printed on 1/29/2018. Page 2 of 45 CMS Manual System, One-Time Notification, Pub. 100-20, Transmittal 477, dated April 24, 2009, Change Request 6338. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity 1. Abstract: Fundus photography Fundus photography uses a special camera to photograph structures behind the lens of the eye including the vitreous, retina, choroids, and optic nerve to document and follow disease processes of the eyes. Extended ophthalmoscopy Extended ophthalmoscopy is the detailed examination of the retina with a detailed drawing. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression. It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina (macula, fundus and periphery) large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination with interpretation and report. The examination must be used for medical decision making. 2. Indications: Fundus photography Fundus Photography is not covered for routine screening. In general, fundus photography is considered medically necessary only when it would assist in: 1. monitoring potential progression of a disease process; or 2. guidance in evaluating the need for or response to a specific treatment or intervention. In other words, medical necessity for fundus photography should guide a clinical decision. Therefore, baseline photos to document a condition that is reasonably expected to be static and/or not require future treatment would not be medically necessary. Such photos to provide a means of comparison to detect, for example, potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with “suspicious” areas, or a nevus or other tumor could be medically necessary. Repeat fundus photography should only be performed at clinically reasonable intervals (i.e., consistent with a noted change on examination or after sufficient time has elapsed for progression or for a treatment to have reasonably had an impact). Specific to this policy, fundus photography to guide a given treatment or intervention (vs. monitoring for progression) e.g., photos used to guide the placement of macular laser treatment or to monitor the response to intraocular vascular endothelial growth factor (VEGF) agents should only be ordered by the physician who actually performs the treatment or intervention. CPT code 92227 (remote imaging for detection of retinal disease, e.g. retinopathy in a patient with diabetes, with analysis and report under physician supervision, unilateral or bilateral) is not for routine screening, but is covered for evaluation of asymptomatic patients at risk with known disease (e.g. diabetes mellitus) that is likely to cause retinal disease when the test is ordered by the treating physician. CPT code 92228 (remote imaging for monitoring and management of active retinal disease, e.g. diabetic retinopathy, with physician review, interpretation and report, unilateral or bilateral) is a covered service when ordered by the treating physician. Extended ophthalmoscopy An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions (THIS LIST MAY NOT BE EXHAUSTIVE): Printed on 1/29/2018. Page 3 of 45 a. Malignant neoplasm of the retina or choroid b. Retained (old) intraocular foreign body, either magnetic or nonmagnetic c. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration d. 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.” e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters) f. Retinal defects without retinal detachment g. 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 h. Sudden visual loss or transient visual loss i. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment j. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye k. Blunt injury to the eye or adnexa l. 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 m. 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 n. Vogt-Koyanagi-Harada syndrome- A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment.