What’s New in 2020 for Retina Coding and Reimbursement
Understanding the changes that occurred on January 1 can help prevent claim denials.
Each new year sees changes in retina coding and reimbursement. In 2020, the most significant changes relate to extended ophthalmoscopy (EO) and modifications of Medicare reporting requirements. A comprehensive knowledge of these changes may help your practice prevent costly denials and receive appropriate reimbursement.
The biggest changes that will affect retina practices were the deletion of CPT codes 92225 (extended ophthalmoscopy with retinal drawing, initial) and 92226 (extended ophthalmoscopy with retinal drawing, subsequent) and the addition of two new codes on January 1. The codes 92225 and 92226 were eliminated because the Relative Value Scale Update Committee determined that initial and subsequent EOs involved similar physician work. The committee also decided that peripheral and posterior examinations had distinct differences.
The new EO codes are:
92201: Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral; and
92202: Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral and bilateral.
Along with these new codes come substantial modifications to the coding principles for EO.
The deleted EO codes were defined as initial (92225) or subsequent (92226). These definitions were eliminated in the new EO codes, which are instead distinguished by the area examined by the doctor during the EO. CPT code 92201 indicates in the descriptor that the EO and retinal drawing of the periphery must include scleral depression; this should be reflected in the documentation. EO for the posterior pole with drawing of optic nerve or macula is now reported with CPT code 92202.
As with the eliminated codes, these new EO codes require the documentation of an interpretation and report. All EO drawings should be legible and include clearly defined labels.
The relative value unit and Medicare reimbursement for EO in 2020 are shown in Table 1. Reimbursement for CPT code 92201 reflects approximately a 9% decrease in value compared with CPT 92225, and CPT 92202 reflects a 32% decrease compared with the deleted initial EO. The total decrease in value may vary by geographic region.
Unilateral Versus Bilateral: Avoid Claim Denials
The 2020 EO codes are defined as “unilateral or bilateral” and may be billed only once per examination regardless of whether bilateral EO was performed. This CPT code indicator change represents a 50% reduction compared with the previous, deleted codes when billed bilaterally.
Due to these changes, the bilateral indicator 2, used to indicate a bilateral payment adjustment, no longer applies. Applying modifiers -RT (right eye), -LT (left eye) or -50 (bilateral procedure) may cause a claim denial.
National Correct Coding Initiative Bundles
According to the National Correct Coding Initiative (NCCI) Version 26.0, which became effective January 1, CPT codes 92201 and 92202 are bundled with all retinal laser procedures and surgeries when performed on the same day. The new EO codes and CPT 92250 (fundus photography) are mutually exclusive, meaning that the two codes may never be unbundled. See Table 2 for more examples of bundled and mutually exclusive coding sets.
There are no new bundles related to retina diagnostic testing services and EO in NCCI Version 26.0, with the exception of fundus photography. Table 3 provides a quick reference of the updated bundles for the first quarter of 2020.
Adjustments in definitions, elimination of unilateral-bilateral distinctions, and reimbursement reductions are significant changes to EO coding in 2020. Table 4 provides a summary of the changes.
MIPS IN 2020
Some changes to the Merit-Based Incentive Payment System (MIPS) will be implemented in 2020. Table 5 outlines these changes.
The minimum final 2020 MIPS score to avoid penalty in 2022 will be 45 points, up from 30 points in 201. The exceptional performance bonus score rose 10 points this year to a total of 85. The stakes for achieving the minimum score are higher, too: The penalty for failing to achieve the minimum score is a 9% reduction in reimbursement.
In 2019, in reporting a quality measure, at least 60% of denominator-eligible patients should have been included. In 2020, that requirement is increased to 70%.
There are considerable changes to quality measures in 2020, along with modifications to requirements promoting interoperability and improvement activity. These changes and other MIPS resources can be found online at aao.org/medicare.
Of note, the weight of each of the four MIPS categories is unchanged in 2020 (Table 6). The performance period for each category will not change.
MASTER CODING IN 2020
Throughout 2020, a commitment to mastering the new coding principles and MIPS changes will be key. The AAO will provide education at aao.org/coding and at Codequest coding courses around the country. The schedule for those courses may be found at aao.org/codequest.
Joy Woodke, COE, OCS, OCSR
• Coding and Practice Management Executive, American Academy of Ophthalmology, San Francisco
• Financial disclosure: None