Ophthalmology and Optometry Coding Alert

Understanding the difference between EO and routine ophthalmoscopy is the key to avoiding denials Because ophthalmologists usually perform some form of ophthalmoscopy during any general exam, knowing when it's OK to report extended ophthalmoscopy can be difficult. Hint: It's up to the physician to prove that an EO is medically necessary and reimbursable.

Use these expert tips for reporting extended ophthalmoscopies to ensure clear sailing for your 92225-92226 claims. Tip 1: Distinguish 'Extended' From 'Routine' General ophthalmological exams (92002-92014) already include routine ophthalmoscopy, often as part of a screening exam, says Donita Baker, education and compliance coordinator for TLC Eyecare and Laser Centers in Jackson, Mich. 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 or an E/M code.

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. A reimbursable EO is one that generates information the ophthalmologist could not have attained through other means (such as a view of the peripheral retina obtained by scleral depression versus indentation), Baker says. Carriers will also reimburse EO when the test generates information that affects or determines the patient's treatment plan.

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. Many glaucoma specialists also perform EO to evaluate the optic nerve.

Do this: Check with your carriers for ICD-9 codes they accept as proving medical necessity for EO. Acceptable codes usually include most codes in the following families: 361.xx (Retinal detachments and defects), 362.xx (Other retinal disorders), 363.xx (Chorioretinal inflammations, scars, and other disorders of choroid) and 365.xx (Glaucoma), says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif. However, most Medicare carriers have specific requirements for reporting the 365.xx range, she says. Tip 2: Don't Fall Into the Modifier 25 Trap 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 code when you are reporting a code for a minor procedure performed during the same visit. However, modifier 25 is not necessary when reporting 92225-92226 with 99201-99215 or 92002-92014--and it may even lead to denials.

This was not always the case, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "Several years ago, for a brief time, it was necessary to append modifier 25 to the eye or E/M [...]