Ophthalmology and Optometry Coding Alert

Question: A patient reports flashes and floaters but the ophthalmologist does not find evidence of retinal pathology on routine ophthalmoscopy. Are we justified in billing for extended ophthalmoscopy (EO)?

Kansas Subscriber

Answer: If the ophthalmoscopy is a routine part of a patient’s eye exam, do not bill for it separately.

However, complaints of flashes and floaters are always serious and must be evaluated carefully; often, these symptoms will justify extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial).

Use 92225 to report a Goldmann-3 exam (examining the retina with a three-mirror goniolens). Remember to provide your formal interpretation and report of the findings in the patient’s medical record. Drawings need to be detailed with labels to show findings in addition to a formal report.

In many cases in which flashers and floaters are present, extended ophthalmoscopy (EO) combined with a retinal exam shows vitreous degeneration or posterior vitreous detachment (379.21, Vitreous degeneration). If an ophthalmologist does not see anything in the routine ophthalmoscopy, he will probably not do an EO. 

Don’t miss: There must be documentation present in the medical record to support the need for an extended ophthalmoscopy whether or not there are findings during the routine ophthalmoscopy. If no documentation exists to show that a routine ophthalmoscopy was performed first and the physician elected to perform an extended ophthalmoscopy immediately, the claim may be denied based on lack of medical necessity.

In the unlikely event that the ophthalmologist doesn’t find any significant problems with the retina after the EO, link 92225 to 379.24 (Disorders of vitreous body; other vitreous opacities). “Vitreous floaters” appears in a note under that code in the ICD-9 manual. If the ophthalmologist does not see floaters, look to the 368.1x series (Subjective visual disturbances).

However: If the ophthalmologist can’t see anything more with an EO than he can see with a routine ophthalmoscopy, defending the use of the EO may be difficult. Some experts recommend not billing for an EO unless there is some abnormality of the retina or vitreous to draw in the report.<!--EndFragment-->m) instead of V67.51. If the patient is still being treated, report Z79.899 (Other long term [current] drug therapy) in place of V58.69.

Some payers also want you to report the E code E931.4 (Antimalarials and drugs acting on other blood protozoa) to identify the drug.