There is a definite love-hate relationship when it comes to electronic health records (EHRs). One of the problems that most physicians are not aware of is these systems’ lack of compliance with Medicare’s guidelines for chart documentation. This review explores the requirements and guidelines for Medicare billing of extended ophthalmoscopy—one of the most audited diagnostic tests in ophthalmology.

CPT DEFINITION

Following is the definition of ophthalmoscopy
from Current Procedural Terminology (CPT):

Routine ophthalmoscopy is part of general and special ophthalmologic services (ie, eye codes and evaluation and management office visit codes) whenever indicated. It is a nonitemized service and is not reported separately.

 

92225 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial

92226 subsequent

 

Note the following guidelines:

  • Medical necessity for the service must be established by noting the presence of a symptom or finding in the chart documentation. The usage cannot be routine.
  • For reimbursement purposes the code is considered unilateral, meaning you are paid for each side independently. Thus, it is crucial that medical necessity—be it a symptom such as floaters or decreased vision or a pathological finding—also be documented for each side.
  • Routine ophthalmoscopic findings or history must be documented in the chart and must support the physician’s decision to proceed to extended ophthalmoscopy.
  • A detailed drawing is mandatory. Without it, Medicare will not consider the service for payment.
  • The difference between “initial” and “subsequent” is not related in any way to the status of the patient as new or established. Rather, use CPT code 92225 when examining a patient for the specific condition for the first time and CPT code 92226 for subsequent examinations for the same condition. Thus, it is quite possible that an initial service (92225) may be coded more than once for a given patient.
  • The interpretation and report (I&R) is mandatory as well, and, again, the service will not be considered for payment without it.

MAC LCD GUIDELINES

Each US state or territory in which Medicare covers residents’ health care services is under the jurisdiction of a Medicare administrative contractor (MAC). The states that are included in a given MAC’s contract varies from contract to contract. For any given service that is not covered by a national coverage determination (NCD), the MAC can issue its own rules for payment. As a payee of Medicare funds, the physician is responsible for being aware of these regulations and abiding by them. They can be found on your MAC’s website, usually under medical policy.

Local coverage determinations (LCDs) that are active should be followed. Those that are retired are not supposed to be used for auditing purposes; however, it is a good idea to be in compliance with them because the auditors will inevitably refer to them internally. If your MAC does not have an LCD, use the one from National Government Services (NGS; Table). The easiest way to access it is to Google NGS Medicare and select Part B under the link to NGSMedicare.com. Next, click on “Medical Policy and Review” in the top bar, then on Medical Policy Center in the dropdown menu. From here, choose Active LCDs for a geographic area, then click on the selected area, which will take you to a CMS listing of policies. L25466 is on the second page entitled “Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)”.

AUDITS REVEAL EHR-SPECIFIC PERILS

The Drawing

Much has been written over the years on the requirements for the drawing originating with the form that accompanied the indirect ophthalmoscope upon purchase. Without the anatomically specific extensive drawing that is mandated by most Medicare MACs, the service simply cannot be billed.

The LCD from NGS Medicare specifies the following:

  • A separate sketch for each eye with a minimum diameter of 4 inches to 6 inches. [Author’s note: Other MACs allow a 3-inch diameter. Smaller drawings may not pass an audit.]
  • The use of between four and six colors is preferred; however, noncolored drawings are also acceptable if clearly labeled.
  • An extensive scaled drawing must accurately represent normal, abnormal, and common findings such as lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachment, holes, tears, or tumors.

EHR Perils and Recommendations
Peril: EHR Drawings

The EHR is good for sketches only—not the detailed information for the drawings required for Medicare. The drawings are difficult to make anatomically specific using this modality, and labeling is not easily performed.

Peril: Cloned Drawings

With the cut-and-paste feature so readily available, some physicians have taken to copying the electronic drawings from encounter to encounter. I have seen this in audits and caution that you cannot bill for the service with cloned material because it will be considered fraud.

Recommendation

If you are adamant about billing for extended ophthalmoscopy and are willing to adhere to all the requirements, then perhaps it is better to use a form and scan the drawing (may include the I&R) into the EHR.

I&R Perils and Recommendations
Peril: Insufficient I&R

This report must contain “the three Cs”: clinical diagnosis, comparative data (if not a new patient), and clinical management. Without this information, the I&R will not be considered complete under audit.

NGS Medicare’s LCD specifically states: “Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report… . The examination must be used in the medical decision-making for the patient.”

Recommendation

Create a template with a few lines for the three Cs to be easily filled in with free text. An alternative would be to fill out a form and then scan it into the patient’s medical record.

Because the provider is being paid additional monies for the test, the I&R should be in a separate position and clearly labeled as an I&R in the chart documentation. This is true for all diagnostic tests.

SHOULD I OR SHOULDN’T I?

The reimbursement for each eye—in metropolitan Philadelphia, Pa., for example—is $28.85 for CPT code 92225 and $26.62 for CPT code 92226 for the latter part of 2015.

A further consideration is the National Correct Coding Initiative code-edit pairs (bundles), wherein extended ophthalmoscopy is bundled into other services that are performed at the same session on the same day. Examples of this are extended ophthalmoscopy plus intravitreal injections, and extended ophthalmoscopy performed the day of a major procedure. Many MACs will not reimburse for extended ophthalmoscopy performed in the global period of a procedure. The services should not be unbundled, with few exceptions such as a new symptom or finding in the fellow eye.

Many providers have elected to forego performing the extensive drawing and the I&R and thus do not bill for extended ophthalmoscopy because of the time and work involved in following the guidelines and requirements. Each physician practices differently, and that is why it is a personal and individual decision. n

Riva Lee Asbell is the principal of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm located in Fort Lauderdale, Fla. Ms. Asbell may be reached at rivalee@rivaleeasbell.com.

CPT codes copyright 2014 American Medical Association.