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Are you Being Denied Payment for Fundus Photography?

I recently had a doctor contact me reporting that he had been getting denied payment from a particular payer for billing fundus photography (92250) with the ICD-10 code for:

  1. D31.31 - Benign neoplasm

of the right choroid

  1. D31.32 - Benign neoplasm of the left choroid

When I looked into this, the payer is determining that since the diagnosis is "benign" there is no reason to take a photograph of the lesion.

Of course one of the benefits of taking a fundus photograph is to evaluate and document the lesion for change. How then, would we describe to the payer in a way that reflects the uncertainty we have that the lesion is truly benign PRIOR TO ordering the photograph even when we are confident the lesion is benign AFTER evaluating that photograph and comparing it to prior photographs/documentation for changes?

One way to describe the lesion in these cases would be to utilize a different code:

  • D49.81 - Neoplasm of unspecified behavior of retina or choroid

  • Dark area on retina

  • Retinal freckle

In this case you are accurately describing to the payer that you are uncertain that the lesion is benign (even though it may likely be) and thus justifying your scrutiny and additional testing.

For further discussion on ordering tests and appropriately interpreting them in the medical record, check out our Complete Billing and Coding Course.

Have a great week!


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