Ophthalmology and Optometry Coding Alert

Don't assign an ICD-9 code before first checking the carrier's local medical review policies for a comprehensive list of acceptable diagnosis codes, Thomas says, and be sure these ICD-9 codes are to the highest degree of specificity using fourth and fifth digits when available. "We always check with our Medicare and Medicaid carriers' policies prior to billing EOs."

If the patient's diagnosis is glaucoma (365.00-365.9), some carriers may indicate additional documentation guidelines. For example, New York state's Medicare EO policy issued by Empire Medicare Services specifies that documentation for a diagnosis of glaucoma "must include all of the following:

1. A detailed drawing of the optic nerve

2. Documentation of cupping, disc rim, pallor, and slope

3. Documentation of any surrounding pathology around the optic nerve."

A look at your carriers' documentation requirements for EOs may surprise you not only is a detailed retinal drawing with interpretation and report required, but often the drug used for dilation and the method of examination must be documented as well.

Carriers' policies will vary on the drawing specifications, but typically the "gold standard" is a 3- to 4-inch color, scale drawing or sketch of the retina. The drawing should include labels for all items in addition to representations of normal, abnormal and even common findings, i.e., retinal detachments and lattice degeneration. Any optic nerve abnormalities should be drawn and labeled separately.

Avoid using preprinted diagrams of the retina as well as depictions of vessels, etc., that are not anatomically correct, especially for Medicare. The drawing should reflect the specific anatomy of the patient being examined, Duran says. In the event of a Medicare audit, poor drawings are not likely acceptable, "and it has been poor drawings that have contributed to the reduction in the value of extended ophthalmoscopies in the past," she adds.

It is a good idea also to include documentation identifying the EO method used, such as the lens and instrument employed. "Typically the instrument used to perform the EO is included in the body of the physician's dictation," Thomas says. You may also want to document whether the pupil was dilated, the drug used, and any patient management plan scrawled in the ophthalmologist's notes.

Just because a patient has had an initial extended ophthalmoscopy does not necessarily mean that all EOs performed after the initial 92225 are "subsequent" and require 92226.

For example, suppose a patient presents seeing flashes, and an initial EO reveals posterior vitreous detachment. Eight weeks later the patient returns for an additional EO billable with 92226 that reveals no worsening of the condition. But two weeks later the same patient revisits the ophthalmologist, this time complaining of floaters and flashes. The third EO should be coded 92225 because the patient is complaining of a new problem.

On the other hand, if a patient with diabetic retinopathy presents for a consultation, the ophthalmologist performs an initial EO, 92225, and the patient returns annually for additional EO checkups, all of the subsequent extended ophthalmoscopies should be coded 92226.

Extended ophthalmoscopies performed during the postoperative period of a surgical procedure performed by the same physician may be included in the global package and are not separately payable, Duran warns, unless there is documented evidence that the motivation for the EO is unrelated to the condition for which the surgery was performed. The postoperative EO should then be coded with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) in addition to the site modifiers, -RT and -LT.

Take care when you are determining the level of E/M service to bill in addition to an extended ophthalmoscopy.

Your level of office visit should not take into account the time and work that went into the EO that work is already included in the payment for 92225 and 92226.

You may also find that your ophthalmologist takes a fundus photograph, 92250 (Fundus photography with interpretation and report), and an extended ophthalmoscopy on the same day. According to Thomas, the fundus photography and EO are separately billable and do not need to be reported with a modifier for separate payment.

However, this is not true for all areas and all Medicare carriers, Duran cautions coders: "There are a couple of carriers that bundle the payment for fundus photography into the payment for the extended ophthalmoscopy, so check your carrier's LMRP to verify whether separate billing is allowed."