Clinical UM Guideline


Subject:Fundus Photography
Guideline #:  CG-MED-47Current Effective Date:  05/13/2013
Status:NewLast Review Date:  05/09/2013

Description

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.

Note: Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

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.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. 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.

CPT 
92250Fundus photography with interpretation and report
  
ICD-9 Diagnosis 
 Including, but not limited to:
042Human immunodeficiency virus (HIV) disease
078.5Cytomegaloviral disease
084.0-084.9Malaria
091.50-091.52Uveitis due to secondary syphilis
094.85Syphilitic retrobulbar neuritis
115.02Infection by Histoplasma capsulatum, retinitis
115.12Infection by Histoplasma duboisii, retinitis
115.92Histoplasmosis, unspecified; retinitis
130.1Conjunctivitis due to toxoplasmosis
130.2Chorioretinitis due to toxoplasmosis
190.0-190.9Malignant neoplasm of eye
198.4Secondary malignant neoplasm of other parts of nervous system
224.0Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
224.5Benign neoplasm of retina
224.6Benign neoplasm of choroid
225.1Benign neoplasm of cranial nerves
234.0Carcinoma in situ of eye
239.81Neoplasm of unspecified nature of retina and choroid
249.00-250.93Diabetes mellitus
282.60-282.69Sickle-cell disease
348.2Benign intracranial hypertension [pseudotumor cerebri]
360.00-360.04Purulent endophthalmitis
360.11-360.19Other endophthalmitis
361.00-361.07Retinal detachment with retinal defect
361.12Serous retinal detachment
361.81-361.89Other forms of retinal detachment
362.01-362.07Diabetic retinopathy
363.00-363.9Chorioretinal inflammations, scars, and other disorders of choroid
365.00-365.9Glaucoma
368.51-368.59Color vision deficiencies
695.4Lupus erythematosus
710.0Systemic lupus erythematosus
714.0-714.9Rheumatoid arthritis and other inflammatory polyarthropathies
743.51-743.59Congenital anomalies of posterior segment
759.5Tuberous sclerosis
771.0-771.2Congenital infection; rubella, cytomegalovirus, malaria, toxoplasmosis
794.11-794.14Abnormal function studies of the eye
871.0-871.9Open wound of eyeball
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 Including, but not limited to:
A50.01Early congenital syphilitic oculopathy
A50.30Late congenital syphilitic oculopathy, unspecified
A50.44Late congenital syphilitic optic nerve atrophy
A51.43Secondary syphilitic oculopathy
A52.15Late syphilitic neuropathy
A52.71Late syphilitic oculopathy
B20Human immunodeficiency virus [HIV] disease
B25.0-B25.9Cytomegalovirus disease
B39.4-B39.9Histoplasmosis
B50.0-B52.9Malaria
B58.00-B58.09Toxoplasma oculopathy
C69.00-C69.92Malignant neoplasm of eye and adnexa
C79.49Secondary malignant neoplasm of other parts of nervous system
D09.20-D09.22Carcinoma in situ of eye
D31.00-D31.92Benign neoplasm of eye and adnexa
D33.3Benign neoplasm of cranial nerves
D49.81Neoplasm of unspecified behavior of retina and choroid
D57.00-D57.819Sickle-cell disorders
E08.00-E11.9Diabetes mellitus
G93.2Benign intracranial hypertension [pseudotumor cerebri]
H30.00-H30.139Chorioretinal inflammation
H30.81-H30.93Other chorioretinal inflammations
H33.001-H33.059Retinal detachments and breaks
H33.20-H33.23Serous retinal detachment
H33.40-H33.43Traction detachment of retina
H33.8Other retinal detachments
H40.001-H40.9Glaucoma
H44.001-H44.19Endophthamitis
H53.50-H53.59Color vision deficiencies
L93.0-L93.2Lupus erythematosus
M05.00-M06.09Rheumatoid arthritis
M06.4Inflammatory polyarthropathy
M32.19Other organ or system involvement in systemic lupus erythematosus
M32.8-M32.9Systemic lupus erythematosus, unspecified
P35.0-P35.9Congenital viral diseases
P37.0-P37.9Other congenital infectious and parasitic diseases
Q14.0-Q14.9Congenital malformation of posterior segment of eye
Q85.1Tuberous sclerosis
R94.110-R94.118Abnormal results of function studies of eye
S05.00XA-S05.92XSInjury of eye and orbit
  
Discussion/General Information

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 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 et al 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.

Definitions

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.

References

Peer Reviewed Publications:

  1. Abràmoff M, Garvin M, Sonka M: Retinal imaging and image analysis. IEEE Rev Biomed Eng 2010; 3: 169–208.
  2. Bernardes R, Serranho P, Lobo C. Digital ocular fundus imaging: a review. Ophthalmologica. 2011; 226(4):161-181.
  3. Ding J, Zou Y, Liu N, et al. Strategies of digital fundus photography for screening diabetic retinopathy in a diabetic population in urban China. Ophthalmic Epidemiol. 2012; 19(6):414-419.
  4. Guigui S, Lifshitz T, Levy J. Screening for diabetic retinopathy: review of current methods. Hosp Pract (Minneap). 2012; 40(2):64-72
  5. Ku JJ, Landers J, Henderson T, Craig JE. The reliability of single-field fundus photography in screening for diabetic retinopathy: the Central Australian Ocular Health Study. Med J Aust. 2013; 198(2):93-96.
  6. Marmor MF, Kellner U, Lai TY, et al. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011; 118(2):415-422.
  7. Shah SU, Seibles J, Park SS. Photographic diabetic retinopathy screening in an urban family practice clinic: effect on compliance to eye examination. Ophthalmic Surg Lasers Imaging. 2011; 42(5):383-389.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Ophthalmology. Preferred Practice Pattern®. For additional information visit the AAO website: http://one.aao.org/CE/PracticeGuidelines/PPP.aspx. Accessed on March 4, 2013.
    • Age-Related Macular Degeneration (September 2008)
    • Diabetic Retinopathy (September 2012)
    • Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration (September 2008)
    • Primary Open-Angle Glaucoma (October 2010)
    • Primary Open-Angle Glaucoma Suspect (October 2010)
  2. National Government Services, Inc. Local Coverage Determination for Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography. Revised 10/01/2012. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?kq=true. Accessed on March 6, 2013.
Web Sites for Additional Information
  1. National Eye Institute. Available at: http://www.nei.nih.gov/. Accessed on March 4, 2013.
Index

Fundus photography

History

Status

Date

Action

New05/09/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.