Ophthalmology and Optometry Coding Alert

Most ophthalmology exams include some form of ophthalmoscopy, and many coders report them almost daily. So how do you know when the exam warrants an extended ophthalmoscopy (EO) code?

You'll have to rely on your physician's detailed documentation to prove medical necessity and capitalize on the more complicated service. Read on to make sure you're not missing out on $2 per exam, which can add up fast.

Any general ophthalmic examination will include a routine ophthalmoscopy, says Sara Root, CPC, coder for the Fletcher Allen Health Care department of ophthalmology in Burlington, Vt. "An extended ophthalmoscopy is a special ophthalmologic service that goes beyond the general eye exam," she says.

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, with interpretation and report; initial; and 92226, ... subsequent) for a more detailed examination. If you're going to code an extended ophthalmoscopy, the ophthalmologist must provide a retinal drawing and interpretation and report, Root says. The documentation should include the reason the ophthalmologist performed an extended exam as well as the procedure he used.

"If a coder ever has a doubt as to what was actually performed, he or she should consult the physician," Root says. "Re-education may need to be provided so that the physician is properly documenting the extended ophthalmoscopy."

When warranted: If the ophthalmologist's documentation justifies reporting an extended ophthalmoscopy code, you have only two codes to choose from. For an initial extended ophthalmoscopy exam use 92225, and for all subsequent exams use 92226. The initial extended ophthalmoscopy exam may not be sufficient to diagnosis a problem, and a subsequent exam may be necessary. You can report one extended ophthalmoscopy per exam based on the physician's documentation, says Katie Stillman, coding specialist for EYE Q Vision in Fresno, Calif.

Although 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 your ophthalmologist provides medical necessity.

Prove it: Carriers will not pay double for bilateral extended ophthalmoscopies unless you can justify medical necessity for performing the exam on both eyes. Don't assume both eyes have the same diagnosis. You must report the correct ICD-9 code(s) with supporting documentation in the medical record to show medical necessity for each eye when performing EO bilaterally. Consult your carriers' local coverage determinations for diagnosis codes that support medical necessity. The range of accepted codes is "pretty wide," Stillman says.

The authoritative resource -- the Medicare Physician Fee Schedule Database (MPFSDB) -- is the resource Medicare carriers and most private payers use to determine payment for the service as bilateral or unilateral. Codes 92225 and 92226 carry a bilateral indicator of "3," which means that payment is based on 100 percent of the fee schedule for each eye.

What to do: Check with your individual payers to see how they want you to report the bilateral procedure.

"Some payers require the code to be reported twice with modifier 50 (Bilateral procedure) appended to the second line. Other payers may request that you bill it on one line with modifier 50," Root says. Still other payers may ask you to use modifiers RT (Right side) and LT (Left side) on separate lines.

Carriers may also specify that the ophthalmologist document the EO drawing using standard colors with detailed labels on the drawing. The size of the drawing may also carry specific payer requirements. Some diagnoses may necessitate an additional separate drawing of the optic nerve. Check with your local carrier for specific instructions and/or guidelines.

There are many times when you have to shy away from reporting more than one service your ophthalmologist performed 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 2008, these special ophthalmologic services may be reported in addition to general ophthalmologic services or E/M codes," Root says. "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 if the documentation supports medical necessity.

Skip 25? In many cases, you need to append modifier 25 (Significant, separately identifiable evaluation and man-agement service by the same physician on the same day of the procedure or other service) to the E/M or eye code when you report a minor procedure performed during the same visit. But you do not need modifier 25 when reporting 92225-92226 with 99201-99215 or 92002-92014, Root says.

But some payers still require you to append modifier 25 to the E/M code when reporting a service from CPT's Medicine section. Therefore, some payers may not pay an extended ophthalmoscopy and an E/M or eye code without modifier 25. Check with your payer to be sure.

Example: If a patient had a standing appointment for a retinopexy and the ophthalmologist performed an extended ophthalmoscopy (92226) during the same visit, "we would bill the retinopexy as 67145 and the extended ophthalmo-scope with 92226 with no modifier," Stillman says.