Fundus Photography (CPB 0539, reviewed 2025-08-21)

By September 4, 2025 (2 weeks from policy date): Billing team must immediately update claim submission rules in billing software to enforce the following: (1) CPT 92250 requires one of 40+ specific ICD-10 diagnosis codes listed as covered indications—claims without these codes will be auto-denied; (2) Implement frequency limit logic to deny claims for more than 2 fundus photography procedures per calendar year unless prior authorization is obtained with documented medical justification; (3) Block billing of CPT 0380T entirely for all Aetna members as it is explicitly non-covered; (4) Do not process baseline fundus photography (CPT 92250) claims when linked to MEK inhibitor therapy initiation (binimetinib, cobimetinib, trametinib) without prior authorization; (5) Create a reference list in the EMR/billing system of the 50+ experimental/unproven indications (e.g., amaurosis fugax, Alzheimer's biomarker screening, checkpoint inhibitor monitoring, tamoxifen use, vincristine use) and flag any claims with these ICD-10 codes for denial. Providers must be notified via email and training to update documentation practices. Front desk staff should inform patients during scheduling that fundus photography requires specific medical conditions and may require prior authorization. Failure to implement these rules will result in systematic claim denials and revenue loss for ophthalmology practices.