Ophthalmology and Optometry Coding Alert

Question: I'm confused about the extended ophthalmoscopy codes. Is 92225 for a new patient and 92226 for an established patient? Should I bill twice for both eyes?

California Subscriber

Answer: The extended ophthalmoscopy (EO) codes, 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 (... subsequent), don't necessarily correspond to new and established patients. CPT does not intend for 92225 to be a one-time-only code,only to be used with new patients. Rather, report 92225 for the initial EO associated with new symptoms of a nonchronic condition.

Example 1: The ophthalmologist sees a patient complaining of flashes and floaters. He performs an initial EO (92225), finding postvitreous detachment. He asks the patient to return in six weeks. At that visit, he  performs an additional EO (92226).

A few weeks after that, the patient returns, now complaining of blurred vision. Since this is a new event, report 92225.

Example 2: A physician refers a diabetic patient to your office for a consultation. The patient has diabetic retinopathy, a chronic condition. At the first appointment, the ophthalmologist performs an initial EO (92225). He asks the patient to return in a year for a dilated exam, at which point he performs a subsequent EO (92226). He returns again in another year for another subsequent EO (92226).

Medicare reimburses both 92225 and 92226 unilaterally, which means that if the ophthalmologist performs EO on both eyes, including the drawing and report, you can report the codes bilaterally and receive twice the payment you would have gotten for one procedure. Append modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) to indicate the bilateral performance of the procedure.

Medicare may also have very specific policies about the requirements for these drawings. In most cases, you should have documented drawings that are 3-4 inches, using 4-6 standard colors that are labeled. In addition, if a patient has glaucoma, the record should have a separate drawing with the optic nerve detailed.

Watch for: Occasionally, it may be necessary to append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 92226, as this code is not considered "diagnostic," if performed during a post-op period for an unrelated diagnosis.