Ophthalmology and Optometry Coding Alert

Heads up, ophthalmology coders: It's time to brush up on the rules for coding diabetic eye screenings.

CMS, the American Academy of Ophthalmology and the American Optometric Association have initiated a national diabetes eye exam program to encourage Medicare beneficiaries with diabetes to have their eyes examined.

The June 14 initiative comes from Medicare's increased emphasis on diabetic eye screening as a preventive service. To make sure your reimbursements are easy to swallow, here's a closer look at coding these preventive tests.

Diabetics have an amplified risk for developing vision problems due to the instability of their blood sugar levels and should therefore receive eye exams at least once annually plenty of incentive to hone your diabetic screening coding.

If the exam takes the form of a consultation at another physician's request, typically the patient's primary-care physician, you should bill a consultation code, 99241-99245. To document consultations correctly, remember the three R's: There must be a Request for consult, a Rendered opinion, and a written Report.

Should you perform a comprehensive exam without a request for a consultation, you can use eye code 92004 or 92014 or an office visit E/M code (9920x-9921x).

Because the three major ophthalmic manifestations of diabetes are diabetic retinopathy, cataracts and glaucoma, it is sometimes necessary to code for special ophthalmological services used to diagnose a manifestation accurately.

For example, a physician may have to perform an extended ophthalmoscopy (EO) to examine and document a patient's retina. Unlike a routine ophthalmoscopy, an extended ophthalmoscopy, 92225 or 92226, requires specific medical necessity that must be documented and indicated by the diagnosis codes. Detailed drawings must be documented with notations of the pathology in exact locations by clock hour.

CMS has set no national guidelines for the drawing requirements. Nor are there specific requirements for documenting the extent of retinopathy a patient is experiencing, says Michael J. Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J. "Verbal descriptions, simple diagrams, extended ophthalmoscopy, or fundus photography with or without fluorescein angiography may be used, depending on circumstances."

But many local Medicare carriers have specific requirements for EO drawings. Some, for example, expect documentation of examination of the ora serrata by scleral depression to ensure proper reimbursement for the procedure. Others require color drawings or drawings of a certain size. Ask your local Medicare carrier if it has a local medical review policy (LMRP) that specifies drawing requirements.

When the ophthalmologist requests fundus photographs when performing EOs, be sure to ask your carrier for its EO and fundus photograph billing policy. Some payers have an LMRP that does not permit billing both on the same date of service.

You should also check for variations of LMRPs for diagnostic testing because they may differ when the patient has diabetes. For instance, it is not medically necessary to perform fluorescein angiography (92230 and 92235), indocyanine-green angiography (92240), or fundus photography (92250) on the same date of service as extended ophthalmoscopy (92225 and 92226), according to AdminaStar Federal, an Indiana carrier, in its extended ophthalmoscopy coding guidelines.

However, according to AdminaStar Federal, Medicare Part B allows coverage for diagnostic ophthalmological services provided to diabetic patients at risk for retinopathy. Eye examinations, E/M services, ophthalmoscopy, fluorescein angioscopy, fluorescein angiography, indocyanine-green angiography, fundus photography, and ophthalmodynamometry are considered payable services when performed for assessment of diabetic retinopathy when the appropriate ICD-9 code for diabetes is reported as the primary diagnosis.

Reimbursement for these tests when provided to diabetic patients is well-received by ophthalmologists, especially since the most common test (for retinopathy in diabetic patients) is fluorescein dye, Yaros says. This test can document the presence and location of micro-aneurysms, the presence and extent of central or peripheral capillary dropout, and the presence and extent of neovas-cularization, he adds. "This test is not needed with all patients," Yaros cautions coders, "only when it assists in diagnosis and treatment."