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 [...]