Ophthalmology and Optometry Coding Alert

Learn what distinguishes EO from the standard ophthalmoscopy included in most eye exams.

Was the ophthalmoscopy your ophthalmologist performed on his last patient just a standard part of a regular eye exam, or was it an extended ophthalmoscopy (EO) that took extra effort -- and deserves extra payment?

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

Read on to make sure you're not missing out on EOs you could rightfully report.

Know When to 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 with 92002-92014.

When an initial exam uncovers a serious retinal problem, retinal specialists then turn to extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], 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 ophthalmologist decides to perform EO with a Volk 78 lens (although the definition of EO does not refer to any particular type of lens, notes David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas). 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.

Remember to Include Detailed EO Documentation

For an initial extended ophthalmoscopy exam on the right eye, use 92225-RT, and for all subsequent exams, use 92226-RT, as the code descriptors indicate. If at a subsequent visit, the ophthalmologist performs an EO on the left eye and a follow-up EO on the right eye, code 92225-LT and 92226-RT, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital Ambulatory and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City.

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.

The documentation should include the medically necessary 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 color drawing 3-4 inches in size, with four to six standard colors, is recommended, but it is not required by every carrier. "Most importantly, the drawing must be detailed with the findings labeled," says Mac. "Typically, if the patient has a diagnosis of glaucoma, a separate detailed drawing of the optic nerve is required. Additionally, the medical record should document whether the pupil was dilated and what drug was used."

Good advice: If you have any documentation concerns on your EO claims, check your payer contract or call the payer before filing.

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. 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 gonioscopy based on the optometrist 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 proves medical necessity.

Skip 25: In many cases, you 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. You do not need modifier 25, however, when reporting 92225-92226 with 99201-99215 or 92002-92014 unless directed to do so by your local carrier or private payers.