Ophthalmology and Optometry Coding Alert

Extended ophthalmoscopy92225 for the first retinal drawing, and 92226 for subsequent drawingsis a potentially lucrative code in the Medicare program, one which may pay more than the accompanying office visit, according to Mary Pat Johnson, COMT, senior consultant with the Corcoran Consulting Group, a San Bernardino, CAbased ophthalmology reimbursement consultant. If you do both eyes for a diabetic, its about $75, says Johnson. For that reason, Medicare wants to make sure you do everything that needs to be donethe drawing, the interpretation and the report. Medicare considers this code to be highly overutilized, she explains. So they will make sure your drawings are what they should be.

What is Required

The drawing specifications are not stipulated by the Health Care Financing Administration (HCFA) as a national policy. Therefore, each local Medicare carrier determines what the specifications are in their jurisdiction. In many carrier areas (notably the northeastern region of the United States), the drawing requirements make this a time-consuming process, and thats why a lot of general ophthalmologists arent billing it anymore, Johnson says.

It takes a lot of time to draw the pictures for carriers in those regions; you could probably see four patients during the time it takes you to do one ophthalmoscopy. And, depending on your carrier, you may be required to draw a picture that is four inches in diameter, with different colored pencilsperhaps three, perhaps more. Some will allow you to use black ink, but you must label everythingincluding normal anatomy. They want all the anatomy, with the pathology, on the drawing, she explains. And usually, the physician cannot have preprinted circles with preprinted anatomy already drawn. You may have the preprinted circle, but not the preprinted anatomy.
The drawing, along with the report, just goes in the chart. But, upon request, you have to produce it, says Johnson. Some ophthalmologists do the ophthalmoscopy without the picturethey look at everything, but just take notes, she adds. Yet, this disqualifies the service from billing codes 92225 and 92226.

Finally, in order to use these codes there must be a disease. You may have a beautiful drawing of a healthy eye, but it wont get paid, says Johnson.

A Necessary Service; Medicare

Extended ophthalmoscopy is a necessary service, says Paul Fernandes, billing manager for Long Island Vitreal Retinal Consultants, a six-ophthalmologist practice in Great Neck, NY. Our perspective is that a retina specialist cannot do his job without extended ophthalmoscopy, says Fernandes.

He concedes that there is a prevailing wave of payers which say, If youre going to do a consult, we wont pay for the ophthalmoscopy. But Fernandes believes in fighting this philosophy. Extended ophthalmoscopy needs to be done, especially for retina and vitreous problems, he maintains.

Interestingly, insurance companiesand, to an extent, Medicareseem to take a similar view of the usefulness of the procedure, except that they want proof that the extended ophthalmoscopy needs to be done. Their requirement is in place to validate medical necessity, explains Fernandes.

For Medicare in New York, the first five extended ophthalmoscopies done in a given year by any physician are paid right away without any medical-necessity note, says Fernandes. But for every one done beyond that, he needs to have the ophthalmologist write a note. This is part of his Medicare carriers policy on payment of these services. Its frustrating, because sometimes the patients previous doctor has done five, and then the patient is referred to us, and were stuck with the sixth, he relates. But he isnt really stuck, because, as he explains, he knows in order to get paid he must have a medical necessity note prepared by the oophthalmologist. Unfortunately, sometimes they wont pay for the sixth, even with that medical-necessity note, says Fernandes. He would like to appeal these rejections, but as his is a very high-volume practice, he hasnt had time.

It isnt easy to find out what the limit is on the number of extended ophthalmoscopies you can do per year, says Fernandes. Our Medicare carrier will only allow a predetermined number of ophthalmoscopies a year, but wont say what the number is, he adds in frustration.
As providers, we would say, How come I was paid last month, but not this month, for extended ophthalmoscopy?

By deduction, he arrived at the number five. Medicare carriers are not allowed by HCFA to publish limits, but they can disclose their frequency guidelines. These are only guidelines and can be overturned if medical necessity exists. When you are asking for this information, recommends Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, ask for the frequency guidelines and not the limits. Usually this information is in their model policy for the service, she explains, so you could also just ask to have a copy of the model policy.

Commercial Carriers Dictate Number Allowed

With commercial HMOs, the issue of how many extended ophthalmoscopies you can do a year is even murkier. Youre pretty much trapped by the contract, says Fernandes. It usually says you have to agree to whatever the policy is. Then, he says, half-joking, you find out after you sign that the policy allows for one extended ophthalmoscopy every leap year. These contracts paint with a broad brush, he says, and if the agreement binds you to the policy, you better be sure what the policy is before you start your appeals.

Tip: Just because a policy is limiting doesnt mean you cant appeal. But knowing what the limits are will help you make the right arguments.

Also, many private HMOs will require a medical-necessity note for every single 92225 and 92226, says Fernandes. These companies will not pay for an extended ophthalmoscopy under any circumstances without a medical-necessity note, and they will still deny the claim, even with the note, if they think it doesnt justify the charge.

Fernandes has found that in many ways, Medicare is much easier to deal with when it comes to 92225 and 92226 than the commercial HMOs and PPOs. As far as Medicare goes, its more organized and together than the private insurance companies, he comments.

Proving Medical Necessity

How do you go about proving medical necessity? You need more than a diagnosis, but thats where you start, says Fernandes, who strongly believes in fighting to get paid for 92225 and 92226. You have to call them [the insurers] and say, How do you expect me to treat a patient with this diagnosis without an extended ophthalmoscopy? How do I cryofreeze if I dont know where the tear is? Yes, you have to get the ophthalmologist involved [in the appeal], and it takes time. I know its a pain, but do it, he adds, especially if youre a small office. If you are doing this in a Medicare environment, you will eventually have a Medicare fair hearing law judge listen to your side (after going through the lower levels of appeal with no success).

Remember that when you file a Medicare claim, the computer system runs the claim and pays or rejects it, explains Fernandes. If you can prove medical necessity during the appeals process, you will win your case.

For a small practice, even a few rejections of 92225 or 92226 would warrant a fair hearing, he believes. For us, it would have to be bigger. But if I can accrue a large number of denials, such as 100 for ophthalmoscopies, well go ahead and fight it, he says.

But theres one thing to remember when it comes to a fair hearing: Dont lose. Be sure you can prove medical necessity in the best interest of the patient, cautions Fernandes. Because if you lose a claim in a fair hearing, you have really set a bad precedent for yourself.

Tip: You dont have to leave the office for a Medicare fair hearing, Fernandes says. You can do the entire hearing on the telephone.

Diagnoses Which Qualify

One big difference between Medicare and commercial HMOs is the number of diagnoses you are allowed for a 92225, our sources agree. Medicare allows a lot of different diagnoses for ophthalmoscopy, says Fernandes. But some private HMOs wont even pay for some retinopathies.

This is a potential problem, because most of the ophthalmoscopies done on non-Medicare patients are done on diabetics. Barbara Yoshihara, coding manager for Crane Eye Care, a two-ophthalmologist practice in Lihue, HI, solves this problem by sending a letter with all non-Medicare claims that are for a consultation and ophthalmoscopy for diabetes. In the letter she explains that the patient is a diabetic and requires an ophthalmoscopy. I do find that ophthalmoscopy is paid, she says.

Additional Codes

Yoshihara uses the eye codes 92002 (intermediate, new patient), 92004 (comprehensive, new patient), 92012 (intermediate, established patient), and 92014 (comprehensive, established patient) with ophthalmoscopy for Medicare patients, and the E/M consult codes (99241-99245 for outpatient consultations) for private insurance. The other alternative is to use either the E/M new patient or consult codes for the office visit along with every ophthalmoscopy.

Another issue involves the use of other ophthalmoscopy codes when you are doing extended ophthalmoscopy. Janet Meyers, office manager for Francois D. Trotta, MD, of Boise, ID, says, We bill color fundus photos (92250) with extended ophthalmoscopy and have no problems getting paid.

Usually, she has a 92225, a 99213 (office/other outpatient visit, established patient) and a 92250. But, if the patient has fluorescein angiograms (92235) on the same day, Meyers handles it differently. I usually bill my fluorescein and fundus photos on separate claims, she says. I put in a remark saying the fundus photos are required for a certain condition. That way, all three codes get paid. For most Medicare carriers, a separate claim would not be necessary, but the remark for the fundus photos would be helpful.

Its important to note that 92225 is for the initial drawing. Subsequent drawings for the same diagnostic condition without a new event must be coded 92226, which pays less. We use 92225 the first time we see a patient, explains Fernandes.