Fundus Photography

Description of Procedure or Service

The retinal fundus is the interior lining of the eyeball and is the area that can be seen through the pupil during an eye examination. Fundus photography involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve. The resultant images may be either photographic or digital and become part of the patient’s permanent record. Fundus photographs are usually taken through a dilated pupil in order to enhance the quality of the photographic record, unless unnecessary for image acquisition or clinically contraindicated.

Fundus photography is used to document abnormalities of the eye or disease progression and may be used for conditions such as macular degeneration, glaucoma, neoplasms of the retina and choroid (benign and malignant), retinal hemorrhages, ischemia, retinal detachment, choroid disturbances, and diabetic retinopathy. It may also be used for assessment of recently performed retinal laser surgery.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for fundus photography when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Fundus Photography is covered

Fundus photography may be considered medically necessary when performed to:

• evaluate abnormalities in the fundus, 
• follow the progress of a disease, 
• plan the treatment for a disease, 
• assess the therapeutic effect of recent surgery (e.g., photocoagulation).

When Fundus Photography is not covered

Fundus photography may be non-covered for routine screening.

Please refer to the Member’s Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. 

Policy Guidelines

Photographs are medically necessary to establish a baseline to judge later if a disease is progressive. An example as follows: It does not add to the patient’s care to photograph dry age related maculopathy to document its existence; however, fundus photography may be necessary to establish the extent of retinal edema in moderate non-proliferative diabetic retinopathy. In four to six months, the baseline photograph can be compared to the clinical appearance of the current diabetic retinal edema to see if it is progressing to clinically significant diabetic macular edema. This information can be used to decide clinical management. The intent of this scenario is to point out how in the former example there is not a therapeutic decision being made; in the latter there is. Fundus photography should aid in making a clinical decision.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 92250

CPT Code 92250 is a bilateral procedure and should be billed only once.

ICD-10 Diagnoses codes that are routine and not covered: H52.00, H52.01, H52.02, H52.03, H52.10, H52.11, H52.12, H52.13, H52.201, H52.202, H52.203, H52.209, H52.211, H52.212, H52.213, H52.219, H52.221, H52.222, H52.223, H52.229, H52.31, H52.32, H52.4, H52.511, H52.512, H52.513, H52.519, H52.521, H52.522, H52.523,H52.529, H52.531, H52.532, H52.533, H52.539, H52.6, H52.7, Z83.3, Z83.511, Z83.518, Z01.00, Z01.01

Scientific Background and Reference Sources

Centers for Medicare and Medicaid Services. Local Coverage Determination for Fundus Photography (L21247). Retrieved July 1, 2009 

Gupta, D (May 2008) Photographing the Fundus. Optometric Management. Retrieved June 1, 2009

BCBSNC Internal Medical Directors' review.

Specialty Matched Consultant Advisory Panel review-6/2011

Specialty Matched Consultant Advisory Panel review-10/2012

Specialty Matched Consultant Advisory Panel review- 6/2013

Specialty Matched Consultant Advisory Panel review- 6/2014

Specialty Matched Consultant Advisory Panel review- 6/2015

Specialty Matched Consultant Advisory Panel review- 6/2016

Specialty Matched Consultant Advisory Panel review- 6/2017

Specialty Matched Consultant Advisory Panel review- 6/2018

Specialty Matched Consultant Advisory Panel review- 6/2019

Specialty Matched Consultant Advisory Panel review- 6/2020

Medical Director review 6/2020

Specialty Matched Consultant Advisory Panel review- 6/2021

Medical Director review 6/2021

Specialty Matched Consultant Advisory Panel review- 6/2022

Medical Director review 6/2022

Specialty Matched Consultant Advisory Panel review- 6/2023

Medical Director review 6/2023

Specialty Matched Consultant Advisory Panel review- 6/2024

Medical Director review 6/2024

Policy Implementation/Update Information

7/20/09 Notification of new policy. Fundus photography may be considered medically necessary when clinically indicated to document a clinically relevant condition that is subject to change in extent, appearance or size, and where such change would directly affect the management. Fundus photography is considered not medically necessary and will not be covered for routine screening. Notification given 7/20/09. Effective date 10/26/09. (pmo)

6/22/10 Policy Number(s) removed (amw)

7/19/11 Specialty Matched Consultant Advisory Panel review 6/29/2011. No changes to policy statement. (lpr).

10/30/12 Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement. (lpr)

7/16/13 Specialty matched consultant advisory panel review 6/19/2013. No change to policy statement. (lpr)

7/15/14 Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. (lpr)

7/28/15 Specialty Matched Consultant Advisory Panel review 6/24/2015. Moved medically necessary indications from Policy Guidelines section to “When Covered” section. Deleted the statement “Fundus photography is not medically necessary simply to document the existence of a condition” from the Policy Guidelines section for clarity. Added the statement “Please refer to the Member’s Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy” to the “When Not Covered” section. Also in the “When Not Covered” section clarified that fundus photography may be non-covered for routine screening and removed the language “considered not medically necessary.” (lpr)

10/1/15 Added ICD-10 diagnoses codes to the Billing/Coding section effective 10/1/15. (lpr)

7/26/16 Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement. (lpr)

7/28/17 Specialty Matched Consultant Advisory Panel review 6/28/2017. No change to policy statement. (lpr)

11/28/17 Added the following statement to the Billing/Coding section for clarification: “ICD-10 Diagnoses codes that are routine and not covered.” No change to policy statement. (lpr)

8/10/18 Specialty Matched Consultant Advisory Panel review 6/2018. No change to policy statement. (lpr)

7/16/19 Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement. (lpr)

6/30/20 Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement. Medical Director review 6/2020. (lpr)

7/13/21 Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review 6/2021. No change to policy statement. (lpr)

7/26/22 Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. (lpr)

7/18/23 Specialty Matched Consultant Advisory Panel review 6/21/2023. Medical Director review 6/2023. No change to policy statement. (lpr)

7/17/24 Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. No change to policy statement. (lpr)