Prior authorization / coding headline — bill 92250 only for listed medical indications

Bill CPT 92250 (Fundus photography with interpretation and report) only when the service aligns with a medically necessary indication listed in the policy; include a supporting ICD-10-CM diagnosis from the policy when submitting the claim or prior authorization to substantiate medical necessity.

• Procedure code: 92250 must correspond to a listed covered indication (see Policy/Criteria I).
• Include one of the enumerated ICD-10-CM diagnosis codes on the claim/authorization to support coverage.

Use listed diagnosis codes to support coverage

Use an ICD-10-CM diagnosis code from the policy’s enumerated lists to support coverage determinations; these diagnosis codes are intended to substantiate the medical necessity of fundus photography when submitted on claims or authorization requests.

• Select a diagnosis code from the ICD-10-CM lists in the policy (examples shown in chunks 18, 21 and others).
• Use laterality- and stage-specific codes when applicable to precisely describe the condition.

Diagnosis codes intended to support prior authorization requests

When submitting prior authorization or claims, include an ICD-10-CM code from the policy’s enumerated list to substantiate the medical indication for fundus photography; the document supplies these codes to support whatever prior authorization processes the plan requires.

• The policy section provides ICD-10-CM codes intended to support prior authorization processes.
• No additional procedural prior authorization rules are stated in this excerpt; use the diagnosis codes to substantiate requests per plan procedures.

Prior authorization requirements not specified in this excerpt

This excerpt does not establish specific procedural prior authorization requirements for fundus photography; follow plan-specific prior authorization processes if present elsewhere in plan materials.

• The policy excerpt notes prior authorization requirements are not specified in this section.
• Check the full policy or plan administrative procedures for any required prior authorization workflows.

Fundus photography does not replace dilated fundus exam; limited screening exception

Do not use fundus photography as a substitute for a comprehensive dilated fundus examination; fundus photography should be employed only when photographic documentation is necessary to ongoing management. Teleretinal diabetic retinopathy evaluations are an exception when patients are non‑compliant with eye exams.

• Fundus photography shall not replace a thorough dilated fundus exam.
• Fundus photography may only be used as a screening tool for teleretinal diabetic retinopathy when the patient is non‑compliant with diabetic eye examinations; a comprehensive diabetic eye evaluation is preferred.

Provider responsibility — use professional judgment

Supplemental note: providers should exercise professional judgment and ensure fundus photography is necessary to ongoing management before ordering or billing the service.

• Providers are expected to exercise professional medical judgment and are responsible for medical advice and treatment.
• This policy is a guide to medical necessity and does not dictate clinical practice; follow plan contract terms and applicable regulations.

Operational coding note — use most specific ICD-10-CM code

Supplemental operational note: reference the policy’s ICD-10-CM lists on claims and prior authorizations and select the most specific code (including laterality/stage qualifiers) to document the clinical indication for imaging.

• Use laterality- and stage-specific ICD-10-CM codes when applicable to precisely document the condition.
• Refer to the policy’s enumerated ICD-10-CM codes to ensure the diagnosis submitted is among those that support coverage.

No step therapy requirements specified in this excerpt

No step therapy requirements for fundus photography are specified in this policy excerpt.

• The document explicitly notes that no step therapy requirements are specified in these chunks.

Documentation expectations — images become part of permanent record; usually dilated

Photographic or digital fundus images become part of the patient's permanent medical record and are usually obtained through a dilated pupil unless unnecessary or clinically contraindicated; only perform fundus photography when photographic documentation is necessary to ongoing management.

• Images become part of the permanent record and are usually taken through a dilated pupil.
• Fundus photography should be employed only when photographic documentation is necessary to ongoing management of the ocular disease process.

Use an enumerated ICD-10-CM diagnosis to support coverage

Use an ICD-10-CM diagnosis code from the policy’s enumerated list on claims and prior authorizations to support coverage for conditions such as diabetic retinopathy, macular edema, retinal detachment, vascular occlusions, and posterior inflammatory conditions.

• Select a supported ICD-10-CM diagnosis from the lists provided in the policy to substantiate medical necessity.
• Common supported categories include E10–E13 diabetes-related retinopathy codes and H30–H35 posterior segment codes.

Use listed ICD-10-CM codes on claims and prior authorization requests

Ensure the ICD-10-CM diagnosis code used on claims and prior authorizations is one of the codes listed in the policy; the policy supplies specific ICD-10-CM codes that should be used to substantiate medical necessity.

• This portion of the policy supplies ICD-10-CM diagnosis codes that support coverage criteria and should be used on claims and prior authorizations.
• Select the code that best matches the patient’s condition, including laterality and staging qualifiers when available.

Provider responsibilities and coverage caveats — exercise professional judgment

Providers must apply their professional medical judgment in ordering and documenting fundus photography; coverage decisions remain subject to the member’s plan contract, state/federal requirements, and Health Plan administrative policies.

• The clinical policy guides medical necessity determinations but does not replace provider clinical judgment.
• Coverage decisions are subject to plan contract terms and applicable laws and administrative policies.

Denial risk — routine replacement, duplicative or repeated imaging may be denied

Potential denial triggers include billing fundus photography for routine replacement of standard ophthalmoscopy, duplicative imaging when no new clinical information is provided, or repeated performance for controlled/stable disease.

• Claims may be denied if fundus photography is billed to document healthy retinal anatomy as a routine replacement for ophthalmoscopy.
• Duplicative documentation with no new clinical information and repeated imaging for stable disease may be denied.

Denial risk — unsupported or missing ICD-10-CM diagnosis code may not support coverage

If the diagnosis submitted is not among the ICD-10-CM codes enumerated in the policy, that diagnosis may not support coverage and could lead to denial; verify the chosen code is listed and appropriately specific.

• Missing or non‑supported ICD-10-CM diagnosis codes from the listed set may not substantiate medical necessity for fundus photography.
• Use the most specific code (including laterality/staging) from the policy lists to avoid coverage challenges.

Coding lists support coverage but do not define procedural prior authorization rules

The policy’s supporting ICD-10-CM code sections list diagnoses that support coverage but do not themselves impose procedural prior authorization rules; follow separate plan authorization rules where applicable.

• This section contains supporting ICD-10-CM codes but does not enumerate procedural prior authorization or documentation requirements.
• Check plan-specific administrative materials for any procedure-level authorization rules.

Not all denial triggers are present in this excerpt — check full policy for additional criteria

Not all denial triggers are listed in this excerpt; providers should be aware that additional denial criteria may exist elsewhere in the full policy or plan administrative rules.

• This excerpt does not contain a comprehensive list of possible denial triggers.
• Review the full clinical policy and plan-level guidance for other coverage/denial criteria.