Fundus Photography and Extended Ophthalmoscopy

The patient's medical record must contain documentation that fully supports the medical necessity for fundus photography and/or extended ophthalmoscopy for each eye, as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Fundus Photography 

A copyof the fundus photographs must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves. The medical record should also document whether the pupil was dilated for the procedure.

Extended Ophthalmoscopy 

Retinal drawings meeting the indicated specifications must be maintained in the patient’s record:

• All items being documented must be clearly identified and labeled.
  
  
• There must be a separate detailed sketch, with a minimum size of approximately four inches in diameter (Retina to periphery or optic nerve margin).
  
  
• An extensive scaled drawing must accurately represent normal, abnormal, and findings of interest in a given patient such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears, or tumors.

Documentation in the patient’s medical record for a diagnosis of glaucoma must include all of the following:

• Optic nerve abnormalities should be documented in a separate drawing from ANY in the retina, and should meet the above size requirements. For example:
  • cupping, disc rim, pallor, and slope
  • any pathology surrounding the optic nerve

Documentation of the specific method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.

The medical record should document whether the pupil was dilated.

All findings and a plan of action should be documented in the patient's medical record supporting the medical necessity for the test(s).

– LCD Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (L33467)