Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

LCD Information Document Information Source LCD ID N/A LCD ID L34399 Original ICD-9 LCD ID Not Applicable LCD Title Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 06/04/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 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Issue Issue Description Annual Review Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter). CMS Publications:CMS Publication 100-04, Medicare Claims Manual, chapter 12: 40.1.A. Global surgery period Coverage Indications, Limitations, and/or Medical Necessity Abstract: Fundus photographyFundus photography involves the use of a retinal camera to document abnormalities of of the retina and disease processes affecting the eye, in order to follow the progress of such disease. The test must be used in the medical decision making for the patient. Extended ophthalmoscopyExtended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy. The examination must be used in the medical decision making for the patient. Indications: Fundus photographyFundus photography may be indicated to document abnormalities of disease processes affecting the eye, or to follow the progress of such disease.In order to document a disease process or follow the progress of a disease, photographs and an interpretation and report of the test may be necessary. Photographs and an interpretation and report of the test may also be necessary to plan treatment for a disease process.Fundus photography may be used for the diagnosis of conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, glaucoma, multiple sclerosis or other central nervous system anomalies.Fundus photography may be indicated for examination of the retina in diabetic patients, in whom symptoms of visual disturbances may be present and in whom retinal examination may be unremarkable or normal. Extended ophthalmoscopyExtended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy.An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions: Malignant neoplasm of the retina or choroid. Retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration. Retinal detachment with or without retinal defect. The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as "a curtain came down over my eyes." Symptoms suggestive of retinal defect (ex: flashes and/or floaters). Retinal defects without retinal detachment. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation. Experienced sudden visual loss or transient visual loss. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment. Sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye. Sustained a blunt injury to the eye or pariorbita. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment). Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders. Posterior scleritis. Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field. Vogt-Koyanagi syndrome. A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea. Degenerative disorders of the globe. Retinoschisis and retinal cysts. Patients may complain of light flashes and floaters. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision. Glaucoma or is a glaucoma suspect. This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve. Systemic disorders which may be associated with retinal pathology. High axial length myopia Retinal edema Metamorphopsia High-risk medication for retinopathy or optic neuropathy. Choroidal nevus being evaluated for malignant transformation. Macular degeneration. Limitations:If the study is performed as a screening service, it is not covered by Medicare. Fundus photography All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary. Fundus photography are bilateral services on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee. Fundus photography is not a substitute for an annual dilated examination by a qualified professional (e.g., in diabetic patients). Fundus photographs taken by a non-eye professional and sent (transtelephonically, via internet, or by other means) to a qualified professional for interpretation are covered for the monitoring and management of active retinal disease. The interpretation of tests done with remote imaging must be performed by a physician or qualified non-physician practitioner. Remote imaging for detection of retinal disease is considered screening and will be denied as non-covered. Provision of fundus photography, by providers other than opthalmologists or optometrists, as a screening test to facilitate referral to a specialist is contrary to requirements for testing as codified in 42CFR 410.32, and is therefore not covered. Furthermore, the ordering/performance of fundus photography by eye specialists prior to a face-to-face encounter is similarly not covered or reimbursable. Extended ophthalmoscopy Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary. General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, but these should still be documented in the patient's medical record. If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated in the attached Article (A57071), the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service. Extended ophthalmoscopy performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed. If the medical record does not include the interpretation and report, the extended ophthalmoscopy will be denied as not medically necessary. Extended ophthalmoscopy will be denied as not medically necessary when it is done in lieu of routine ophthalmoscopy unless the indication for this more extensive examination is documented in the medical record. When other ophthalmological tests (e.g., fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: Fundus photography Fundus photography involves the use of a retinal camera to document abnormalities of of the retina and disease processes affecting the eye, in order to follow the progress of such disease. The test must be used in the medical decision making for the patient. Extended ophthalmoscopy Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report . It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy. The examination must be used in the medical decision making for the patient. Indications: Fundus photography Fundus photography may be indicated to document abnormalities of disease processes affecting the eye, or to follow the progress of such disease. In order to document a disease process or follow the progress of a disease, photographs and an interpretation and report of the test may be necessary. Photographs and an interpretation and report of the test may also be necessary to plan treatment for a disease process. Fundus photography may be used for the diagnosis of conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, glaucoma, multiple sclerosis or other central nervous system anomalies. Fundus photography may be indicated for examination of the retina in diabetic patients, in whom symptoms of visual disturbances may be present and in whom retinal examination may be unremarkable or normal. Extended ophthalmoscopy Extended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy. An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions: Malignant neoplasm of the retina or choroid. Retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration. Retinal detachment with or without retinal defect. The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as "a curtain came down over my eyes." Symptoms suggestive of retinal defect (ex: flashes and/or floaters). Retinal defects without retinal detachment. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation. Experienced sudden visual loss or transient visual loss. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment. Sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye. Sustained a blunt injury to the eye or pariorbita. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment). Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders. Posterior scleritis. Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field. Vogt-Koyanagi syndrome. A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea. Degenerative disorders of the globe. Retinoschisis and retinal cysts. Patients may complain of light flashes and floaters. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision. Glaucoma or is a glaucoma suspect. This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve. Systemic disorders which may be associated with retinal pathology. High axial length myopia Retinal edema Metamorphopsia High-risk medication for retinopathy or optic neuropathy. Choroidal nevus being evaluated for malignant transformation. Macular degeneration. Limitations: If the study is performed as a screening service, it is not covered by Medicare. Fundus photography All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary. Fundus photography are bilateral services on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee. Fundus photography is not a substitute for an annual dilated examination by a qualified professional (e.g., in diabetic patients). Fundus photographs taken by a non-eye professional and sent (transtelephonically, via internet, or by other means) to a qualified professional for interpretation are covered for the monitoring and management of active retinal disease. The interpretation of tests done with remote imaging must be performed by a physician or qualified non-physician practitioner. Remote imaging for detection of retinal disease is considered screening and will be denied as non-covered. Provision of fundus photography, by providers other than opthalmologists or optometrists, as a screening test to facilitate referral to a specialist is contrary to requirements for testing as codified in 42CFR 410.32, and is therefore not covered. Furthermore, the ordering/performance of fundus photography by eye specialists prior to a face-to-face encounter is similarly not covered or reimbursable. Extended ophthalmoscopy Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary. General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, but these should still be documented in the patient's medical record. If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated in the attached Article (A57071), the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service. Extended ophthalmoscopy performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed. If the medical record does not include the interpretation and report, the extended ophthalmoscopy will be denied as not medically necessary. Extended ophthalmoscopy will be denied as not medically necessary when it is done in lieu of routine ophthalmoscopy unless the indication for this more extensive examination is documented in the medical record. When other ophthalmological tests (e.g., fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.