Clinical UM Guideline
|Guideline #:||CG-MED-47||Current Effective Date:||07/15/2014|
|Status:||Reviewed||Last Review Date:||05/15/2014|
Fundus photography uses a retinal camera to photograph the regions of the vitreous, retina, choroid, and optic nerve to document abnormalities related to disease processes affecting the eye or to follow the progress of the disease in response to therapy. The photographs can be taken with a 35mm camera or digitally.
Fundus photography is considered medically necessary to document abnormalities or disease processes (not screening) affecting the eye or to follow the progress of such eye disease when the results of fundus photography will be used to direct therapy and improve clinical outcomes. Examples include but are not limited to the following:
Repeat or sequential fundus photographs are considered medically necessary only if they document a condition with the potential to change in appearance or size of the eye, and where such change would alter treatment.
Not Medically Necessary:
Fundus photography is considered not medically necessary when the criteria outlined above are not met and for all other conditions, including screening for ocular disorders.
Fundus photography is considered not medically necessary for retinopathy screening in individuals treated with chloroquine and hydroxychlorquine anti-malarial therapies.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|92250||Fundus photography with interpretation and report|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|Including, but not limited to:|
|042||Human immunodeficiency virus (HIV) disease|
|091.50-091.52||Uveitis due to secondary syphilis|
|094.85||Syphilitic retrobulbar neuritis|
|115.02||Infection by Histoplasma capsulatum, retinitis|
|115.12||Infection by Histoplasma duboisii, retinitis|
|115.92||Histoplasmosis, unspecified; retinitis|
|130.1||Conjunctivitis due to toxoplasmosis|
|130.2||Chorioretinitis due to toxoplasmosis|
|190.0-190.9||Malignant neoplasm of eye|
|198.4||Secondary malignant neoplasm of other parts of nervous system|
|224.0||Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid|
|224.5||Benign neoplasm of retina|
|224.6||Benign neoplasm of choroid|
|225.1||Benign neoplasm of cranial nerves|
|234.0||Carcinoma in situ of eye|
|239.81||Neoplasm of unspecified nature of retina and choroid|
|348.2||Benign intracranial hypertension [pseudotumor cerebri]|
|361.00-361.07||Retinal detachment with retinal defect|
|361.12||Serous retinal detachment|
|361.81-361.89||Other forms of retinal detachment|
|363.00-363.9||Chorioretinal inflammations, scars, and other disorders of choroid|
|368.51-368.59||Color vision deficiencies|
|710.0||Systemic lupus erythematosus|
|714.0-714.9||Rheumatoid arthritis and other inflammatory polyarthropathies|
|743.51-743.59||Congenital anomalies of posterior segment|
|771.0-771.2||Congenital infection; rubella, cytomegalovirus, malaria, toxoplasmosis|
|794.11-794.14||Abnormal function studies of the eye|
|871.0-871.9||Open wound of eyeball|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|Including, but not limited to:|
|A50.01||Early congenital syphilitic oculopathy|
|A50.30||Late congenital syphilitic oculopathy, unspecified|
|A50.44||Late congenital syphilitic optic nerve atrophy|
|A51.43||Secondary syphilitic oculopathy|
|A52.15||Late syphilitic neuropathy|
|A52.71||Late syphilitic oculopathy|
|B20||Human immunodeficiency virus [HIV] disease|
|C69.00-C69.92||Malignant neoplasm of eye and adnexa|
|C79.49||Secondary malignant neoplasm of other parts of nervous system|
|D09.20-D09.22||Carcinoma in situ of eye|
|D31.00-D31.92||Benign neoplasm of eye and adnexa|
|D33.3||Benign neoplasm of cranial nerves|
|D49.81||Neoplasm of unspecified behavior of retina and choroid|
|G93.2||Benign intracranial hypertension [pseudotumor cerebri]|
|H30.81-H30.93||Other chorioretinal inflammations|
|H33.001-H33.059||Retinal detachments and breaks|
|H33.20-H33.23||Serous retinal detachment|
|H33.40-H33.43||Traction detachment of retina|
|H33.8||Other retinal detachments|
|H53.50-H53.59||Color vision deficiencies|
|M32.19||Other organ or system involvement in systemic lupus erythematosus|
|M32.8-M32.9||Systemic lupus erythematosus, unspecified|
|P35.0-P35.9||Congenital viral diseases|
|P37.0-P37.9||Other congenital infectious and parasitic diseases|
|Q14.0-Q14.9||Congenital malformation of posterior segment of eye|
|R94.110-R94.118||Abnormal results of function studies of eye|
|S05.00XA-S05.92XS||Injury of eye and orbit|
Imaging of the fundus is useful to check its status and assess for any changes from a healthy condition of the eye. Fundus imaging can focus on the structure or function of the retina or diagnose ocular diseases. Because of the architecture of the retina and its function, diseases of the eye and diseases which affect circulation and the brain can start in the retina. Ocular diseases including glaucoma, age-related macular degeneration, diabetic retinopathy and systemic diseases such as multiple sclerosis can affect the retina.
Diabetic retinopathy is characterized by damage to the blood vessels in the retina. Diabetic retinopathy is the most common eye disease in diabetics and is a leading cause of blindness in American adults. It is caused by changes in the blood vessels of the retina. A 2013 study by Ku and colleagues reported on 360 individuals (706 eyes) who had fundus photographs and self-reported diabetes. Upon clinical grading of the photographs, 163 eyes had diabetic retinopathy and 51 eyes had vision-threatening diabetic retinopathy. The sensitivity for detecting diabetic retinopathy was 74% with a specificity of 92%; for vision-threatening diabetic retinopathy, sensitivity was 86% and specificity was 95%. The authors concluded that fundus photography was a valid screening tool for diabetic retinopathy.
The American Academy of Ophthalmology 2012 Preferred Practice Pattern® for diabetic retinopathy reports that the use of fundus photography has little value in the cases of minimal diabetic retinopathy or when the diabetic retinopathy is unchanged from prior photographs, but fundus photography may be useful for documenting disease progression and treatment response.
Glaucoma is a group of diseases that damage the optic nerve of the eye and can lead to vision loss and blindness. The American Academy of Ophthalmology has a Preferred Practice Pattern for primary open-angle glaucoma (2010) and primary open-angle glaucoma suspect (2010) and both recommend examination of the retinal nerve fiber layer of the fundus to include photography. While the most desirable techniques for evaluating the optic nerve head and retinal nerve fiber layer are stereophotography or computer-based imaging, a nonstereoscopic photograph is an alternative.
Recommendations by the American Academy of Ophthalmology (Marmor, 2011) do not advise the use of fundus photography for screening for chloroquine and hydroxychloroquine retinopathy from anti-malarial medication. They state that fundus photography should be used for documentation and monitoring purposes, but if bull's eye maculopathy is visible this is considered to be a late change and the goal of screening is to find toxicity at an earlier stage.
Choroid: The vascular layer of the eye that lies between the retina and the sclera. It provides nourishment to outer layers of the retina.
Fundus: The interior surface of the eye, opposite the lens. The fundus includes the retina, optic disc, macula, fovea, and posterior pole.
Glaucoma: A disease characterized by destruction of the nerve fiber layer of the optic disc.
Optic nerve: The nerve that carries images of what is seen from the eye to the brain.
Retina: The light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain.
Vitreous body: A transparent jellylike substance that fills the posterior segment of the eye, delimited by the hyaloid membrane.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
|Reviewed||05/15/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, References and History sections.|
|New||05/09/2013||MPTAC review. Initial document development.|