Ophthalmology and Optometry Coding Alert

The general ophthalmological services codes, or eye codes, are automatically considered bilateral when reported and should never be used with modifier -50 (Bilateral procedure), says Marianne F. Wink, RHIT, compliance analyst and educator for the University of Rochester Medical Center in New York. "Generally where the modifier is needed is for a procedure that identifies one or the other eye only," perhaps with the special ophthalmological procedures, for example.

When reporting these codes for a unilateral procedure, or if only one eye is assessed, you must use modifier -52 (Reduced services) to indicate that the full service(s) reported was not fully rendered, Wink says. "This does not affect reimbursement, it is informational," she says, and CPT and LMRPs don't state both eyes must be evaluated.

Mydriasis, a long-continued or excessive dilation of the pupil, is used to facilitate visualization of the ocular media and fundus. It is added in the definition to help distinguish between the intermediate and comprehensive levels of service. The use of mydriasis and examination of the posterior segment is more extensive than an examination of the anterior segment only.

Extended ophthalmoscopies, 92225-92226, are reported separately and should not be confused with standard ophthalmoscopies, which are included in the eye codes.

You should definitely and will have to report the special ophthalmological services, 92015-92140, in addition to the eye codes if you use eye codes rather than E/M codes to report office visits. Testing services do not require the use of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), because they are not considered minor procedures. Minor procedures have a postoperative period of 0 or 10 days and require that modifier -25 be used on the eye code or E/M service when the definition is met.

So if an established patient presents for a routine comprehensive evaluation of the function of his eye and has an extended ophthalmoscopy, you will need to code 92014 and 92225. But be careful of your local medical review policies and/or payment policy from your carrier. Some carriers have a long-time edit in place not to pay for extended ophthalmoscopy (92225-92226) when billed with 92014. If this is the case in your area, you either need to bill the services and end up in the review and appeal process proving medical necessity or must select the intermediate-eye-level code or E/M code instead of the comprehensive eye code.