At A Glance
- Extended ophthalmoscopy (EO) is an extensive examination of the fundus for a specific condition. It is distinct from routine ophthalmoscopy performed as part of a standard eye exam.
- EO requires that an additional diagnostic technique, such as 360° scleral depression, fundus contact lens, or 90-D lens be performed and documented.
- There are two different CPT codes for EO: one for the initial study and one for a subsequent study.
What do commercial payers’ audits and CMS’ Target, Probe and Educate audits currently have in common? Both are now targeting extended and subsequent ophthalmoscopy to ensure that documentation consistently meets the payer’s requirements.
DEFINING EXTENDED OPHTHALMOSCOPY
Extended ophthalmoscopy (EO) is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy performed during an eye exam. It includes examination of the periphery of the eye, with dilation, and is performed for specific conditions. There are two different CPT codes for EO, one for the initial study and one for a subsequent study. The CPT code definitions can be found in Table 1.
Routine ophthalmoscopy, including routine direct and indirect ophthalmoscopy, is considered part of a standard eye examination and is included under the appropriate level of evaluation and management (also called E/M) or Eye visit code. EO, by contrast, is a more extensive examination that requires a detailed, labeled drawing of pathology that cannot be documented in any other way. It also requires that an additional diagnostic technique be performed and documented, which may include 360° scleral depression, fundus contact lens, or 90-D lens.
Initial Versus Subsequent
Determining the correct CPT code for EO starts with understanding the difference between initial and subsequent. This distinction does not refer to a new versus established patient, but rather to the diagnosis of an initial event (CPT 92225) and then, if relevant, a subsequent documentation of the progression of a chronic condition (CPT 92226).
For example, an established patient is seen and an extended examination by scleral depression is performed. The retina specialist confirms the diagnosis of macular hole in the right eye and documents it with a retinal drawing with labels and an interpretation and report. The correct code for this EO would be 92225 Ophthalmoscopy, extended, initial.
A few months later, this same patient returns for an examination, and another EO is performed by scleral depression. The macular hole is worsening, and the retina specialist documents this with a retinal drawing and interpretation and report. This EO would be coded 92226 Ophthalmoscopy, extended, subsequent.
If the same patient is seen 6 months later for a retinal tear that is determined by EO and documented accordingly, because this is the initial diagnosis of a new problem, 92225 would be the appropriate CPT code to bill for this service.
CPT codes 92225 and 92226 both have a bilateral indicator of 3. This means that, when performed bilaterally with pathology, the reimbursement will be 100% allowable per eye. Most insurance carriers prefer the -RT, -LT, or -50 modifier to indicate bilateral services.
Each quarter, Medicare publishes National Correct Coding Initiative (NCCI) edits to identify CPT codes that are considered bundled and not separately payable when performed on the same day. A link to these edits can be found at aao.org/coding and in the AAO’s Complete Guide to Retina Coding.
Since July 2013, EO has been bundled with retinal lasers, injections, and surgeries when performed the same day.
See Table 2 for an example of the NCCI edits for 92225 and 92226 EO and for 67028 intravitreal injection and 67108 repair of retinal detachment.
There are two types of bundled codes: mutually exclusive, which can never be unbundled and have an indicator of 0, and comprehensive, which have an indicator of 1 and may be paid separately under limited circumstances and must meet the definition of modifier -59 or per specific local coverage determinations (LCDs).
The NCCI bundles for EO have an indicator of 1. When is it appropriate to unbundle an EO performed on the same day as a surgery? When EO is performed and pathology is diagnosed in the fellow eye, not the eye undergoing surgery.
To determine the documentation and medical necessity requirements for EO, each payer policy should be reviewed. Medicare Administrative Contractors (MACs) may have relevant LCDs or local coverage articles. Commercial payers may also publish policies related to these services.
Although coverage policies vary by payer, here are some basic requirements to keep in mind when coding for EO services:
- Documentation of medical necessity;
- A drawing that is clearly identified, labeled, and appropriately represents the retinal pathology;
- Interpretation and report;
- Extended fundus exam with documentation of diagnostic technique (eg, 90-D lens);
- Assessment of change in pathology for subsequent EO.
There are four MACs that have policies related to EO. Each of these policies is unique and should be reviewed for guidance if you practice in that jurisdiction. To review and maintain a current copy of the published LCDs per MAC, visit aao.org/lcds.
Table 3 provides a list of active LCDs for EO regarding specific MACs’ definitions of medical necessity or specific documentation requirements. For example, First Coast Service Options, the MAC for Jurisdiction N, indicates in its LCD L34017 that medical records must include the following:
- Complaint or symptoms necessitating the EO;
- Notation of the dilation and drug used for the examined eye;
- Method of examination;
- “A detailed drawing of the retina showing anatomy in the patient as seen at the time of examination, including the pathology found and a legible narrative report of the findings”;
- For 92226, assessment of the change from previous encounters.
The LCD for First Coast Service Options continues with coding guidelines for ophthalmoscopy in a supplemental fact sheet discussing bilateral coding for EO codes 92225 and 92226:
- Usual payment adjustment for bilateral procedures does not apply;
- Do not append -50 modifier, report codes on separate lines appending -RT or -LT modifiers;
- Proper coding will prevent duplicate billing and allow full reimbursement per eye.
As another example, National Government Services (NGS), the MAC for Jurisdictions 6 and K, has unique requirements related to the retinal drawing in its LCD L33567:
- Size, 3 to 4 inches;
- Drawing must be identified and labeled;
- Noncolored drawings are acceptable, but color drawings with 4 to 6 standard colors are preferred;
- Separate drawing for optic nerve abnormalities.
Additional guidance regarding exclusive bundles is outlined in the NGS LCD. Although not bundled under NCCI, the NGS LCD specifies that EO performed with fundus photography (CPT 92250), fluorescein angiography (CPT 92235), ultrasound (76512), or OCT (CPT 92134) will be denied as not medically necessary. The physician must provide a “reasonable medical exception” for performing EO and “additive (nonduplicative) information.”
CREATING A CHECKLIST
Insurance policies often provide requirements for medical necessity and documentation. From these policies, your office can create an internal checklist to be used as a resource. The checklist on the next page represents typical requirements and should be revised per individual payers’ policies. This resource can provide guidance for internal audits and can be used as a training resource.