DEC 03, 2018
Billing Fundus Photos and OCT Same Day to Commercial Payers
Question: We need your advice on billing CPT 92250 Fundus photos and CPT code 92134 Retina OCT the same day for patients with commercial insurances.
Answer: Best to review the policy for your commercial payers directly. These two codes have a CCI edit bundle, however they can be unbundled with modifier -59. Some MACs with policies state when it can be unbundled. The physician can choose to unbundle when they feel appropriate, just be prepared to defend your documentation and reasoning.
Don’t submit fundus photos due to higher allowable, as some payers expect the OCT to be submitted with treatment. Also there are frequency edits that may not always be published. If only billing one test, bill the one that provides the most information.
Commercial payers may have their own edits or follow the CCI edits, so again, it’s always best to confirm.
Learn more about testing in the Retina Coding: Complete Reference Guide.