Ophthalmology and Optometry Coding Alert

Sometimes ophthalmologists will provide extended ophthalmoscopy (92225, initial drawing, 92226, subsequent drawings) in addition to comprehensive general ophthalmological services (92004, new patient, and 92014, established patient). But Cindy Gersich, insurance representative for U.P. Ophthalmology, a three-ophthalmologist practice in Escanaba, MI, tells us that Medicare is denying the 92225 part of the claim. We call them, and they tell us to look in the manual, but theres nothing in the manual, she says. Because Gersichs physicians do quite a bit of retinal work, she is concerned about this lack of payment.

According to Michelle Ciuffi, insurance biller for McComiskey and Lanoux, a two-ophthalmologist practice in New Orleans, LA, it should not be a problem to bill these codes together. We do bill 92014 and 92225 together, says Ciuffi. Its very important that you put the drawings in the patients chart, but you dont need to send the drawings with the claim. The other thing you need is the correct diagnosis, which supports medical necessity. For Ciuffi, this means any diagnosis codes that relate to the macular, vascular, or choroidal parts of the eye. Theyll definitely deny it unless the diagnosis is correct, Ciuffi says.

There is nothing in the CPT manual which would give a payer justification to deny 92225 along with an office visit, either an evaluation and management (E/M) service or an eye exam. According to CPT, routine ophthalmoscopy is indeed part of general and special ophthalmologic services. But extended ophthalmoscopy includes a drawing of the retina, with interpretation and report. Furthermore, Medicare carriers have designated certain colors to be used in these drawings, but some carriers require more differentiation than others. Ophthalmoscopy codes 92225, 92226, 92230, 92235, 92240, 92250, and 92260 can be reported separately; however, these codes are not considered routine ophthalmoscopy.

We asked Ciuffi when she does use 92226subsequent extended ophthalmoscopy. We dont, she says. We have only used the initial code.

But sometimes there is a reason to use 92226. Subsequent drawings for the same diagnostic condition without a new event must be coded 92226, which pays less. The insurance and billing clerk for Retina and Vitreous, a three-ophthalmologist practice in South Bend, IN, says that once surgery is done, there usually isnt a need for a second drawing. We seldom use 92226, the clerk says.

And this billing clerk has no trouble getting reimbursed for 92225 as well as an office visit; she uses consultation codes, but not the eye exam codes. As subspecialists, the doctors usually just see new patients by consultation. She generally uses a bilateral modifier (-50) on the extended ophthalmoscopy, since the doctors usually draw both eyes.

Determine Correct Code Level

Another issue is the level of E/M or eye code used, says Lise Roberts, vice president of Healthcare Compliance Strategies, based in Syosset, NY, and a top ophthalmology coding consultant. If your documentation shows a history, anterior segment exam, and detailed drawing of the posterior segment, and you will be coding an extended ophthalmoscopy, then you have already billed the payer for the posterior segment exam documented by the detailed drawing, Roberts says. In this case you should mentally cover up the drawing and look at what is left over in the examination to determine whether the exam portion of the service was problem-focused, expanded problem-focused, detailed, or comprehensive for the E/M codes, she says. For the eye codes, look at whether there is separate documentation from the detailed drawing that is sufficient to meet the criteria set forth by your local Medicare carrier for a comprehensive eye examination.

With the eye examination codes, Roberts notes, if you do not have sufficient documentation and you dont include the detailed drawing for a comprehensive examination, code an intermediate eye exam or a lower level E/M service.

Coding for New and Established Patients

For new patient and consultation E/M codes you must have a comprehensive examination documented exclusive of the detailed drawing in order to use either 99204, 99244, 99205, or 99245. For established patients, if the history is detailed and the medical decision-making is moderate, you could code 99214, according to Roberts. If the history is complete and the medical decision-making is high, you could code 99215. If either the history or the medical decision-making do not meet the criteria for the code you think is correct, then the examination documentation exclusive of the detailed drawing would have to be either detailed or comprehensive in order to use fourth or fifth level E/M codes. This is true for established patients because only two of the three key components (history, examination, and medical decision-making) must meet the criteria for documentation set out in the code description in the CPT manual. New patient and consultation codes must document all three of the key components.