Ophthalmology and Optometry Coding Alert

Ensure you know what qualifies as an EO, and go beyond routine coding.

Most eye exams include some form of ophthalmoscopy, but payers often bundle this service into the general ophthalmic exam, or E/M codes So how do you know when the exam warrants an extended ophthalmoscopy (EO) code? You'll have to provide more detailed documentation and drawings to prove medical necessity and support code assignment for the more complicated service.

Read on to make sure you're not missing out on EOs you could rightfully report. Know When Underlying Problems Can Take Coding to the Next Level Any general ophthalmic examination will include a routine ophthalmoscopy. But an extended ophthalmoscopy is a special ophthalmologic service that goes beyond the general eye exam.

Caution: The general ophthalmic examination codes (92002-92014) already include the routine ophthalmoscopy, so you should not report routine ophthalmoscopy (which can include a slit lamp examination with a Hruby lens or direct ophthalmoscopy for fundus examination) separately.

When an initial exam uncovers a serious retinal problem, retinal specialists then turn to extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing, with interpretation and report; initial; and 92226, ... subsequent) for a more detailed examination.

Consider this example: An obese female patient presents with headaches, slightly reduced vision in her right eye, vague complaints of soreness and variable blur. A routine ophthalmoscopy shows an elevated disc, so the physician decides to perform EO with a Volk 78 lens (although the definition of EO does not refer to any particular type of lens). The EO reveals papilledema.

On this claim, report the following:

• 92225 for the EO
• modifier RT (Right side) appended to 92225 to show that you are only billing for the patient's right eye
• 377.00 (Papilledema, unspecified) linked to 92225 to prove medical necessity for the EO.

Make EO Documentation Show Exam Reason

For an initial extended ophthalmoscopy exam, use 92225-RT, and for all subsequent exams of the right eye, use 92226-RT, as the code descriptors indicate. While standard documentation will be sufficient for your routine ophthalmoscopy claims, you'll need more notes to back up your EO claims. EO is a detailed, extra, separate procedure requiring additional documentation with interpretation and report.

Tip: The documentation should include the reason the ophthalmologist performed an extended exam as well as the procedure he used.

Also include a drawing of the area on the fundus in question (like the disc). A detailed and labeled color drawing, using standard colors, would be best, but it is not required by every carrier, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Best Practices-Network Operations at Mount Sinai Hospital in New York City. Some payers may also require a specific size of the drawing (e.g., four inches).

If you have any documentation concerns on your EO claims, check your local and/or national payer guidelines or call the payer before filing a claim.

Bill Bilaterally Based on Carrier

While you're unable to report most of the other ophthalmic testing codes in the 92xxx series bilaterally, you can report 92225 and 92226 for each eye -- if there is a medically necessary reason.

EO is a unilateral procedure. Although CPT doesn't specifically describe the procedure as unilateral in the code descriptor, most insurers follow Medicare's lead. You can find the bilateral surgery indicators in the fee schedule, says Sylvia Conrad, insurance coordinator with Your Eye Solution in Jacksonville, Fla.

Check column Z of the database, marked "Bilat Surg." The fee schedule assigns 92225 a bilateral surgery indicator of "3," which means that Medicare has set the relative value units (RVUs) for  extended ophthalmoscopy based on the ophthalmologist performing the procedure unilaterally. If there is a problem with both eyes, you can report the service for both eyes. Depending on insurer preference, report bilateral EOs with either:

• 92225-50 (Bilateral procedure) or
• 92225-RT (Right side) and 92225-LT (Left side).

Prove it: Don't assume both eyes have the same diagnosis.

You must report ICD-9 codes showing medical necessity in each eye you performed EO on. Consult your carriers' local coverage determinations for diagnosis codes that support medical necessity.

Don't Rule Out Other Services

There are many times when you have to shy away from reporting more than one service during an encounter. When both services are medically necessary, however, you can report an extended ophthalmoscopy on the same day as a minor procedure or other service.

CPT classifies extended ophthalmoscopies as special ophthalmologic services. According to CPT 2010, these special ophthalmologic services may be reported in addition to general ophthalmologic services or E/M codes.

Often the extended ophthalmoscopy is what determines if a minor or major procedure is necessary. You can therefore report 92225 and 92226 within the global period of another procedure as well, if the documentation supports medical necessity.

Consider this example: A new patient presents for a routine eye exam with no significant complaints except a diagnosis of type 2 diabetes. Her last exam was 18 months ago and she does not recall being told of any ocular complications of her diabetes. The exam reveals dot/blot hemorrhages and exudates in both eyes, but the right eye is worse. The ophthalmologist documents the areas of disease in both eyes and orders an OCT (92135, Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) of the macula to further evaluate the macula since some of the exudates superior to the macula could be affecting macula integrity.

In this instance, you should report the EO codes and fundus photos. On the claim, include the following along with your EO codes:

• 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) for the general exam
• 92225-LT (Left side) to represent the EO
• 92250-LT (Fundus photography with interpretation and report)
• 362.83 (Retinal edema) linked to 92014, 92225 and
• 92250 to support medical necessity for the encounter and diagnostic tests.

Append or skip modifier 25? In many cases, you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same  day of the procedure or other service) to the E/M or eye service code when you are reporting a code for a minor procedure performed during the same visit.