Ophthalmology and Optometry Coding Alert

 
Depending on the location, Medicare carriers have widely varying requirements for the retinal drawing, which is included in extended ophthalmoscopy, 92225 (ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 ... subsequent). An ophthalmologist in New York may have to use certain colors to designate different parts of the retinal anatomy, while in Pennsylvania he or she may be required to provide an "extensive scaled drawing" with no mention of particular colors.
 
Ophthalmologists perform extended ophthalmoscopy (EO) in many circumstances. For example, EO might be performed on a patient who has a known posterior- segment problem or signs or symptoms of it. Less often, EO might be performed when, in the course of routine ophthalmoscopy, the physician discovers pathology that calls for more study. Routine ophthalmoscopy is not separately billable but is included in comprehensive ophthalmic services (92004 and 92014) and E/M codes that require a comprehensive level examination.
 
If your state does not have a local medical review policy (LMRP) for 92225, check surrounding states for guidance. Because 92225 has been overused, some carriers have very specific documentation requirements, particularly for the drawing. CPT requires the drawing only for 92225 and 92226.
 
Although the drawing may require extensive work depending on the carrier, do not submit it with the claim. It stays in the file, where it is available to the carrier upon request.
 
As complex as these drawing requirements may seem, most retinologists are trained to draw in the way required by the stricter LMRPs, says Lise Roberts, vice president of Health Care Compliance Strategies in Jericho, N.Y. It helps them check on the progress of a condition. The strict drawing requirements of some carriers are due to overuse of the codes, particularly in some parts of the country. "The LMRPs were created to curb the usage of the code, and they have worked," Roberts says. "Even some retinologists don't like to use these codes anymore."

 
While very common and in the vast majority of cases benign, "flashes" and "floaters" can signify a retinal tear or break. The sooner a retinal tear is repaired, the greater the chance sight can be saved, so ophthalmologists examine anyone who complains of flashes or floaters as soon as possible.
 
In most patients, the flashes and floaters are a posterior vitreous detachment (PVD, 379.21). The ophthalmologist can only ascertain whether the problem is PVD or a retinal tear/detachment by performing EO. Use 379.21 first, and use symptom of photopsia (flashes, 368.15) or floaters (379.24) second for carriers with LMRPs that cover EOs for a PVD diagnosis. For carriers that don't have PVD on their LMRP list of diagnoses, use the symptom codes as primary. 
 
It can be a challenge to depict in a drawing symptoms that are subjective, such as flashes, and those that have no universal documentation, such as floaters. The drawing ends up looking normal. Nevertheless, you must complete the drawing but with a notation that the patient has the positive finding of PVD and that there are no holes, tears or detachments.
 
"You can indicate that PVD is there by saying so on the drawing," says Kitty Timmes, COMT, office manager for Joseph J. Timmes Jr., MD, FACP, a retinologists practicing in Annandale, Va. As Roberts notes, "Negative findings have equal weight as positive findings in documentation."
 
The ophthalmologist typically calls the patient back for a subsequent EO (92226) within six weeks to verify that the PVD didn't develop into a tear or detachment.  The diagnosis for this visit is PVD if there is no tear or detachment. Use the appropriate code from the range 361.00-361.89 if there is a retinal tear or detachment.
 
"Our doctors -- all general ophthalmologists -- don't do EO for flashes and floaters," says Tracy Plummer, CMM, office manager for Eye Physicians and Surgeons of Western New York in Rochester (where Upstate Medicare is the carrier). "They do it mostly for retinal tears and sometimes for a new patient who is a diabetic."

 
When an LMRP requires only that a drawing be "extensive," it can be challenging for coders to gauge the meaning. Auditors working with vague LMRPs generally check to make sure the physician looked beyond the routine fundus examination, using techniques indicative of EO, due to symptoms or diagnoses that are approved for EO reimbursement and that there is a reasonably informative drawing. This would include specific documentation of the patient's anatomy, not a preprinted form of normal anatomy.

 
You can bill an office visit or consultation in addition to 92225 or 92226, but be careful about using the work done for the EO to determine the level of the E/M service; you are already being paid for that work in 92225 or 92226.
 
You must also consider whether the patient is Medicare, Medicaid or commercial HMO, Roberts says.
 
Medicaid typically bundles 92225 and 92226 into the visit or consultation code and pays for just the visit or consultation, Roberts says. Many HMOs and PPOs do the same thing.
 
Medicare says you can code 92225 or 92226 and the visit separately and be paid for 92225 or 92226 for each eye (be paid twice for the code). The best way to list this on a claim form is on two lines, using the -RT modifier on the end of the EO code on one line and the -LT modifier on the other.
 
Note: Some Medicare carriers prefer that you list this as a single line using modifier -50 (bilateral procedure).
 
A typical chart for an E/M or eye exam visit when extended ophthalmoscopy was performed might document the history, the anterior exam done with a slit lamp, the dilation of the patient, and the drawing of the retina. You cannot use the extended ophthalmoscopy documentation for the E/M visit if you are billing the EOs separately -- that would be double-dipping. EO is a separate code having its own work unit values and requiring its own documentation. "Look at what's left over in the documentation, not at the EO or the drawing, and use that to determine the E/M or eye exam code level," Roberts says.

 
Sometimes a physician can use a higher-level E/M or eye exam code in addition to the EO if the payer is Medicare. For example, the doctor may perform a regular eye exam when the patient has not reported an ocular symptom or condition that indicates a need for EO. This regular exam may include indirect ophthalmoscopy (not separately billable, but included with the eye exam). The physician sees something on examination and proceeds to EO. For example, by seeing tortuous blood vessels in the back of the eye, the ophthalmologist may discover high blood pressure the patient didn't know about. Or the ophthalmologist may be the first physician to discover signs of diabetes by retinal changes, or there may be a retinal blastoma. These are all examples of a potentially higher-level E/M or eye examination that could be coded in addition to 92225. Such a visit might be coded fourth level (such as 99204) plus 92225 for each eye. 
 
An EO visit done for flashes and floaters, in which a posterior vitreal detachment is discovered, might be only a level three as well as 92225, depending on the documentation and what was medically necessary to do in the visit.
 
But if the payer is Medicaid or a commercial HMO, you may not be able to be paid for both the 92225 and the office visit, regardless of the patient's problem. If you code for Medicaid the way you code for Medicare, for the typical EO (done for a patient with flashes and floaters, for example) you might only bill a level-three E/M service because the EO is coded separately. Medicaid then denies the EO and pays only the level-three E/M. So when coding for Medicaid, HMOs and PPOs, consider all the services you have provided, including extended ophthalmoscopy, in determining the visit level and do not code the EO separately. Then, you might be in a position to bill this visit as a level-four E/M or a comprehensive eye exam depending on the work done and the documentation.

 
LMRPs for EO range from extremely vague to extremely prescriptive. The drawing requirements alone are onerous in some states, and medical necessity differs as well. Below are some comparisons of various carriers.

 
1. Medical conditions. A serious retinal condition must exist or be suspected based on routine ophthalmoscopy. The ophthalmologist must determine that further studies are required, such as:
 

preretinal membrane
 

a macular hole
 

a significant macular edema
 

a 360-degree scleral depression
 

a retinal tear
 

detachment
 

uncontrolled glaucoma (only if the optic nerve and  changes must be drawn)
 

sudden-onset floaters or vitreous hemorrhage possibly due to retinal tear
 

suspected wet age-related macular degeneration
 

proliferative diabetic retinopathy
 

intraocular foreign body
 

retinal vascular occlusion
 

posterior vitreous detachment.

 
The list of acceptable ICD-9 codes is long but includes such common maladies as migraine (346.xx) and vitreous floaters (379.24). Most of the globe disorders (360.xx), retinal defects (361.xx, 362.xx), choroidal problems (363.xx), optic-nerve disorders (377.xx), visual disturbances (368.xx), malignant neoplasms (190.5, 190.6) and open wounds (871.x) are included.
 
2. Drawing requirements. Retinal drawings must be legible, extensive and to scale. Include both normal and abnormal findings.

 
1. Medical conditions. The medical-necessity list for upstate New York is unremarkable, but the drawing requirements make up for that.
 
2. Drawing requirements. New York features some of the most prescriptive requirements in the country for retinal drawings.
 
The drawing sketch must be at least 3 to 4 inches large. All drawings should be in the "standard" colors: red, blue, yellow, green, purple, orange and brown. Draw optic-nerve abnormalities separately.
 
Below is what the colors mean:
 

Red: retinal arteries, retinal hemorrhages, attached retina
 

Blue: retinal veins, detached retina
 

Yellow: chorioretinal exudates, intraretinal exudates, intraretinal edema
 

Green: opacities in media, vitreous hemorrhage
 

Purple: flat neovascularization
 

Orange: elevated neovascularization
 

Brown: retinal pigment epithelium or choroidal pigmentation seen through attached retina; vascular occlusion
 

Blue outline filled with red: full-thickness sensory retinal break
 

Blue outline filled with red: partial-thickness sensory retinal break
 

Black outline filled with black lattice pattern: lattice degeneration of attached retina
 

Blue outline filled with blue lattice pattern: lattice degeneration of detached retina
 

Black outline cross-hatched with red: paving-stone degeneration of attached retina
 

Brown outline cross-hatched with red: paving-stone degeneration seen through detached retina
 

Blue lines (short): retinal tufts and meridional folds
 

Black scalloped line overlying ora serrata circle on fundus chart: ora serrata with adjacent attached retina
 

Blue scalloped line overlying ora serrata circle on fundus chart: ora serrata with adjacent detached retina
 

Green outline filled with red: red blood in vitreous.
  
Administar Federal -- Kentucky

 
Administar Federal, which covers Kentucky and Indiana, has an LMRP for 92225 in Kentucky.
 
1. Medical conditions. More liberal in its medical- necessity list than some carriers, Administar Federal's Kentucky LMRP includes borderline glaucoma (365.00-365.04); transient visual loss (368.12); diabetes mellitus (250.00-250.93); diabetes mellitus with pregnancy, childbirth, and the puerperium (648.00-648.04); systemic lupus (710.0); and rheumatoid arthritis (714.0-714.9) as covered diagnoses for EO.
 
2. Drawing requirements. All Administar requires for the drawing -- in addition to legibility -- is that the optic nerve be drawn in detail. All other documentation, including documentation of any surrounding pathology around the optic nerve, may be written in report fashion. However, Administar requires that the complaint or symptomatology be reflected in an "appropriate drawing."

 
1. Medical conditions. In New Jersey, Empire Medicare Services, like most carriers with LMRPs for 92225, stresses malignant neoplasms, retinal problems and traumas. However, possible retinal problems, as evidenced by floaters and flashes, also justify 92225 in New Jersey.
 
2. Drawing requirements. Empire Medicare requires an "extensive scaled drawing" that must be at least 3 to 4 inches in size. The drawing must show normal and abnormal findings, such as lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, and retinal detachments, holes, tears or tumors. Empire Medicare in New Jersey also requires that all items in the drawing be "identified and labeled." If there are optic-nerve abnormalities, they should be separately drawn. And while the LMRP stops short of the detailed color requirements for Upstate New York, it does say that use of the standard colors is "highly recommended."

 
1. Medical conditions. Georgia Medicare requires that extended ophthalmoscopy must provide new information that will affect the treatment plan. The carrier will not pay for 92225 if done merely to confirm information available otherwise. Evaluations of tumors and retinal detachments or defects are covered, as are many other specific diagnoses. But the LMRP states that 92225 and 92226 are only for the "meticulous evaluation" of a "severe ophthalmologic problem when photography is not adequate or appropriate."
 
2. Drawing requirements. The drawing must be "a three-dimensional representation or an extended colored retinal drawing." This means that the carrier wants to see some shading, not just a drawing of a circle with the words describing the cupping underneath. Alternatively, they want colored pencils. Ophthalmologists may not use templates or sketches. It's permissible to use a drawing of a circle, but not one in which the vessels of the eye are preprinted. Specific colors, or what they should represent, are not mentioned.

 
1. Medical conditions. In Iowa, Noridian, which covers many states, covers diagnoses that include neoplasms, glaucoma, vitreous disorders, retinal and chorioretinal problems, lens dislocations and wounds. Visual disturbances like flashes and floaters are not covered.
 
2. Drawing requirements. The Noridian-Iowa LMRP for 92225 says only that the code includes a drawing of the retina. No other mention is made of the drawing itself.