Ophthalmology and Optometry Coding Alert

Find out which retinal imaging claims require saved images.

Diabetic retinopathy is an eye condition that may develop in people with diabetes and uncontrolled hyperglycemia. If the retinopathy is not managed properly, it can lead to loss of vision. Luckily, technological advances in the field of ophthalmology have made retinal imaging more widely available and spurred changes to the Special Ophthalmological Services subsection in the Medicine section of the CPT^® 2021 code set.

Just as coders were wrapping their heads around the updates, subsequent coding guidance in CPT^® Assistant (volume 31, issue 1) added to the confusion surrounding the proper application of these codes. This left many of you with a lot of questions about reporting retinal imaging services. So, we set out to find the answers, and here’s what we’ve discovered.

Get to Know Remote Retinal Imaging Codes

Codes 92227-92229 describe work related to imaging the retina for disease detection or monitoring. The codes are differentiated based on who reads the images and where the review, interpretation, and analysis take place.

• 92227 (Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report, unilateral or bilateral)
• 92228 (… with remote physician or other qualified health care professional interpre­tation and report, unilateral or bilateral)
• 92229 (… point-of-care autonomous analysis and report, unilateral or bilateral)

When a trained technician or clinical staff review and report the imaging results in a remote site, different from the location where the images are acquired, you’ll use 92227. This service is primarily for the early detection of diabetic retinopathy. Once retinopathy is detected, a physician typically performs the review and report, which you’ll bill with 92228. Look to 92229 when an imaging system takes retinal images, automatically interprets the data, and produces clinically relevant conclusions.

“Code 92229 is reported when computer software is used to test for retinal diseases, such as diabetic retinopathy, using a point-of-care automated analysis,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. The software interprets the fundus photographs and provides an immediate report with findings. “This report may include management recommendations at the point of care,” Moore adds.

Note: “There are reporting restrictions for certain services listed within the Special Ophthalmological Services subsection (eg, scanning computerized ophthalmic diagnostic imaging of the posterior segment — optic nerve [92133] or retina [92134]) in conjunction with the other retinal imaging detection of disease (92227-92229) or with fundus photography (92250),” per CPT^® Assistant.

Check These Clarifications to Clear Up Any Confusion

Several months following the release of the initial guidance on reporting remote retinal imaging procedures, CPT^® Assistant published a follow-up article in June (volume 31, issue 6) to minimize misunderstandings. Here are the key takeaways:

The structure of codes 92227-92229 is not typical in terms of hierarchy. Even though these codes share the same base description, each code is unique as defined by the entity reviewing and reporting.

The work of the clinical staff to position the patient before the retinal camera and obtain images of each eye is considered part of the practice expense for these services.

When retinal imaging is performed, you may report an evaluation and management (E/M) service code separately “in addition to code 92229 to account for physician or other QHP work, such as discussing the imaging test results with the patient and the potential need for follow-up with an ophthalmologist or optometrist for treatment, as appropriate,” the June CPT^® Assistant notes.

Coding alert: The retinal imaging code descriptors say, “unilateral or bilateral.” From a CPT^® perspective, that means you should not append modifier 50 (Bilateral procedure) to the code when the services are performed bilaterally. In fact, Medicare considers them inherently bilateral and prices them as such, and other payers may do the same. So, if your provider performs a service unilaterally, “you could be subject to a fee reduction,” cautioned Gail O’Leary of NGS Medicare, a Medicare Administrative Contractor (MAC), during NGS’s “Vision Services” webinar.

Retain Thorough Documentation for Posterior Segment Imaging

Other types of posterior segment imaging performed by ophthalmologists include fundus photography and extended ophthalmoscopy, which you’ll report with the following codes:

• 92201 (Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral)
• 92202 (… with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral)
• 92250 (Fundus photography with interpretation and report)

“Fundus photography involves the use of a retinal camera to document abnormalities of the retina and disease processes affecting the eye in order to follow the progress of such diseases,” O’Leary said. “The test must be used in the medical decision making of the patient.”

Fundus photography claims must include a written interpretation, and the documentation should clarify whether the pupil was dilated and which dilation drug was used. “A copy of the fundus photographs must be retained in the patient’s medical records, in addition to the interpretation and report,” O’Leary stressed. Without the photo, the code’s professional and technical components will be denied. These codes are inherently bilateral, and if you perform this unilaterally, you could be subject to a fee reduction, she noted.

“Then you’ve got extended ophthalmoscopy, which is the detailed examination of the retina and always includes a true drawing of the retina with interpretation and report,” she said. “It is performed by the physician when a more detailed examination is needed following routine ophthalmoscopy, and it must be used in the medical decision making of the patient,” O’Leary noted.

Extended ophthalmoscopy is indicated when the level of exam requires a complete review of the posterior segment of the eye and documentation is greater than that required of general ophthalmoscopy, she added. However, it’s not covered by Medicare when it’s performed only as a screening service.

“Extended ophthalmoscopy has several coverage limitations, which you can read in the LCD. For instance, performing it on a fellow eye without signs/symptoms or new abnormalities will be denied as not medically necessary,” she said.

The medical record for extended ophthalmoscopy must include a relevant medical history, physical exam, and pertinent diagnostic test results/procedures to support medical necessity.

“Retinal drawings [92201] must meet certain specifications as indicated in the LCD,” she added.

Frequency guidelines for extended ophthalmoscopy may differ based on the patient’s condition, so check the LCD for that information. In addition, O’Leary noted extended ophthalmoscopy performed during the global package of a related ophthalmic surgery is not separately billable.