Ophthalmology and Optometry Coding Alert

Question: Could you shed some light on billing 92225 or 92226 with modifier 50, RT/LT, or two units for a newborn who is in the neonatal intensive care unit (NICU)? How do you determine medical necessity for billing twice?

Answer: Both 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 (... subsequent) are inherently unilateral, so you can get reimbursement for extended opthalmoscopies (EOs) performed on both eyes provided 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 insurer's policy for diagnosis codes that support medical necessity. Always code diagnoses based on the MD's documentation. The range of accepted codes is pretty wide. For instance, insurers may accept 362.83 (Retinal edema) and 377.00 (Papilledema, unspecified) to prove medical necessity for an EO.

For the initial ophthalmoscopy performed on both eyes, report 92225-RT and 92225-LT. Alternatively, you may report the service once and append modifier 50 (92225-50). If a subsequent drawing is needed on a different date of service, you would report 92226-50 on one line or on separate lines with RT/LT. Some insurers may follow Medicare's requirement of reporting the code once appended with modifier 50 (Bilateral procedure).

Other payers may want the code reported twice with modifier 50 appended to the second line, while others may want modifiers LT (Left side) and RT (Right side) on separate lines.

Although your inquiry deals with newborns who are not on Medicare, you may want to highlight Medicare's payment and documentation policies for 92225 and 92226. The 2011 Medicare Physician Fee Schedule does not apply a bilateral procedure payment adjustment to these codes. Documentation policies may require a specific size of the drawing using different colors, and most policies require a detailed and labeled drawing. Additionally, a legible narrative report of findings is required.