Ophthalmology and Optometry Coding Alert

Question: How should I bill for extended ophthalmoscopy (92225-92226)? Is one code for a new patient and the other for an established patient? Should I bill twice for both eyes?

California Subscriber

 

Answer: Unless your Medicare carrier has a local medical review policy (LMRP) that says you can bill 92225 only one time, these codes refer to "initial" and "subsequent," not "new" and "established." The CPT principle behind this language comes from hospital coding: When a recurrence of a condition requires hospitalization, the initial hospital visit code may be used again for the new admission. Per CPT, 92225 is not intended to be a one-time-only code. Use 92225 for the initial extended ophthalmoscopy (EO) of new symptoms of a nonchronic condition, such as new flashes and floaters.

 

Scenario: Flashes and floaters. You see a patient for a complaint of flashes and floaters, and perform an initial EO (92225). You find postvitreous detachment, and ask the patient to return within six weeks.

At the subsequent visit, you perform an additional EO (92226). You find that the retina is intact, and educate the patient about retinal detachment. 

A few weeks later, the patient asks for a new appointment because she sees a spider web and new flashes, and you must perform another EO. Bill this as 92225 because it is a new event.

 

 

Scenario: Diabetic retinopathy. A physician refers a diabetic patient to you for a consultation. The patent has diabetic retinopathy, a chronic condition. At the first appointment, you perform an initial EO (92225). You ask the patient to return in a year for a dilated examination. In a year you perform a subsequent EO (92226). You do the same thing the following year, and again bill 92226, and so on.

 

Bilateral coding. Codes 92225 and 92226 are unilateral codes in the Medicare program. If it is medically necessary to perform the procedure in both eyes -- and you perform the drawing and report for both eyes you can choose one of two coding options: 92225-50 (bilateral procedure) as a single-line bill, or 92225-RT (right side) and 92225-LT (left side) on two lines. Rarely, a carrier will want units, so check with your carrier for any unit requirements. Make sure your documentation of medical necessity supports billing bilaterally. 

 

Other procedures. Check with your carrier. Administar, in an LMRP effective May 15, indicates that fluorescein angioscopy and angiography codes 92230, 92235, 92240 or 92250 may not be billed on the same date as 92225 or 92226. 

 

Documentation. All carriers that have rules for retinal drawings publish them in LMRPs. Not all carriers have established what the specific nature of the drawing must be. Administar's new LMRP for Indiana, for example, requires the drawing be on a "full-size sheet of paper." The eye must be at least 2.5 inches in diameter. You must use at least three colors to document the pathology. Make sure the drawing is to scale and gives a "three-dimensional representation of the pathology." When evaluating maculopathy, include choroidal lesions or fluid under the retina. If you performed the EO without dilation, you must document why the dilation was not done. Any optic-nerve abnormalities should be drawn separately. Note that you can never bill 92225 and 92226 on the same date.