Ophthalmology and Optometry Coding Alert

If your ophthalmic practice is like most, every day you have several ophthalmoscopies cross your desk. With $23.50 on the line for 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and $21.22 for 92226 (... subsequent), based on the 2008 National Medicare Physician Fee Schedule Allowables, coding mistakes can add up quickly. Are you sure you're coding each extended ophthalmoscopy (EO) correctly?

Note: You can find many of the answers to these questions in "Go Beyond Routine Coding for Extended Ophthalmoscopies" and "Fast Facts About 92225-92226," in Ophthalmology Coding Alert Vol. 11, No. 3.

You may not report an ophthalmoscopy separately when the ophthalmologist has also performed a general ophthalmic examination (92002-92014) on the same day. True or false?

Answer: False. Although any general ophthalmic exam will include a routine ophthalmoscopy (which can include a slit lamp exam with a Hruby lens or direct ophthalmoscopy for fundus examination), you may be able to report extended ophthalmoscopy if the ophthalmologist has documented medical necessity.

Documentation should include a detailed and labeled retinal drawing along with an interpretation and report. Some carriers also require a specific size and use of four-six standard colors to label the retinal drawing. Also, be sure to provide the reason the ophthalmologist performed the EO as well as the procedure he used.

The ophthalmologist sees a new patient complaining of flashes and floaters. He performs an initial EO, finding post-vitreous detachment. He asks the patient to return in six weeks. At that visit, he performs a subsequent EO. A few weeks after that, the patient returns, now complaining of blurred vision. The ophthalmologist performs another EO. How should you code for the three EOs?

A: 92225 for all three EOs

B: 92226 for all three EOs

C: 92225 for the first EO, 92226 for the second and third

D: 92225 for the first EO, 92226 for the second, and 92225 for the third

E: None of the above.

Answer: D. Report 92225 for the initial EO and 92226 for the follow-up EO the ophthalmologist performed after six weeks. Code 92226 is appropriate because the ophthalmologist is following up on the post-vitreous attachment. When the patient returns with the blurred vision complaint, the ophthalmologist is then investigating a new condition, so report 92225.

On the other hand, payers consider 92226 to be a "physician service" and not a "diagnostic service." If you report this service in the post-op period for a related diagnosis, some payers may not reimburse for it.

If you report the service during the post-op period for an unrelated diagnosis, append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the code, and link to the new diagnosis.

Remember: The "initial" and "subsequent" EO codes don't necessarily correspond to new and established patients. CPT does not intend for 92225 to be a one-time-only code you should only use with new patients. Rather, report 92225 for the initial EO associated with new symptoms of a non-chronic condition -- in this example, the flashers and floaters and the blurred vision.

Extended ophthalmoscopy is an inherently bilateral procedure. True or false?

Answer: False. Both 92225 and 92226 are inherently unilateral, so you can get reimbursement for EOs performed on both eyes -- if the ophthalmologist shows medical necessity for both. You must report ICD-9 codes illustrating medical necessity for each eye. Don't assume that both eyes have the same diagnosis. Consult your carrier's local coverage determination (LCD) for diagnosis codes that support medical necessity -- but always code diagnoses based on the MD's documentation.

Your coding may change depending on the carrier. Some providers want the code reported twice with modifier 50 (Bilateral procedure) appended to the second line, while others may want modifiers LT (Left side) and RT (Right side) on separate lines. Check the carrier's LCD for instructions.

According to the Correct Coding Initiative (CCI), EO is bundled with:

A: scanning laser tests (92135)

B: fluorescein angiography (92235)

C: fundus photography (92250)

D: all of these

E: none of these.

Answer: E. CCI doesn't bundle any of these procedures with 92225 or 92226. But that doesn't mean you're automatically in the clear with all carriers -- some may have their own rules for what other procedures you can code with EO.

For example, many Part B carriers, including HealthNow UMD in New York, consider 92225 and 92226 "generally not necessary" with scanning laser tests (92135, Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser] with interpretation and report, unilateral) such as the HRT, GDX and OCT tests.

Medi-Cal, California's Medicaid program, also refuses to reimburse for 92250 (Fundus photography with interpretation and report) performed on the same day as 92225. And HMO Tufts Health Plan will not reimburse 92225 or 92226 when billed with 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) "as 92225 and 92226 are included in 92235." Tufts will consider reimbursement if you use the appropriate modifier, however.

Best bet: Ask the carrier for its EO bundling rules.