Confusion Over EO:
Medicare Requirements Depend on Your Location
Published on Sat Sep 01, 2001
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."
Flashes and Floaters
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 [...]
