Ophthalmology and Optometry Coding Alert

Until Medicare establishes national guidelines for billing extended ophthalmoscopies (EO), following a few widely accepted criteria for billing EOs will deter unwanted attention from auditors. Extended ophthalmoscopy is the examination of the posterior segment of the eye through an indirect ophthalmoscope or fundus contact lens, for example, for the purpose of diagnosing retinal disease and disorder. EOs are examinations with drawings of what the physician is seeing in the retina and surrounding area, says Paula Thomas, CPC, ophthalmology coder with Southeastern Retina Associates in Chattanooga, Tenn. In general, extended ophthalmoscopies are warranted in cases of serious retinal disorders (e.g., retinal detachment) that constitute medical necessity, and they require detailed documentation. Extended ophthalmoscopy is also performed by many glaucoma specialists to evaluate the optic nerve, "but not all Medicare carriers allow coverage and payment for the service when billed with a diagnosis code from the glaucoma range," says Raequell Duran, president, Practice Solutions, Santa Barbara, Calif. Don't Take EO Medical Necessity Lightly A defining difference between routine and extended ophthalmoscopies is that EOs are used strictly for patients with identifiable symptoms of retinal disease or already-diagnosed diseases, whereas routine ophthalmoscopies may be used as screening exams that are included in comprehensive eye exams.

Common patient complaints and conditions warranting initial extended ophthalmoscopies, 92225, include the following:

"Flashes" (368.15) and "floaters" (379.24) potential indicators of media or retinal disorders (361.00-362.9), advanced nerve head damage from glaucoma (365.00-365.89) or post-vitreous detachment (379.21)

Diabetic retinopathy a chronic condition (362.01-362.02 with 250.5) that can be a precursor to or coincide with retinal disorders

History of retinal complications past retinal detachment, retinal holes, retinal vein occlusion, etc., puts patients at a higher risk of retinal disorders constituting medical necessity. 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." Document to Death 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 [...]