Ophthalmology and Optometry Coding Alert

Extended ophthalmoscopy (92225, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial drawing; 92226, subsequent drawings) is an essential tool for retina specialists, and some general ophthalmologists do it as well. But there are sometimes problems getting paid. These problems stem from the fact that retina specialists tend to use these codes much more than general ophthalmologists do.

Our orientation here is retina and vitreous, so we do this procedure a lot, explains Paul Fernandes, billing manager for Long Island Vitreo Retinal Consultants, a six-ophthalmologist practice in Great Neck, NY. Recently, Fernandes opened his mail to find a letter from Medicare stating that one of his physicians had been audited.

They compared him to 900 ophthalmologists, and said he was overutilizing 92225, recalls Fernandes. They said that they were comparing him to his peers, but they were comparing him to all ophthalmologists, not specifically retina specialists.

Fernandes called his Medicare carrier immediately. I explained to the young lady who was responsible for the audit that we are retinal specialists, and that we have to do 92225 when we see many patients. The representative understood, and said that the matter was solved.

Protect Yourself: Put it in Writing

But that wasnt enough for Fernandes. I wrote a letter saying that we are retina specialists, and explaining why we have medical necessity to do 92225, he says. (For the basic text of this letter, which Fernandes has many opportunities to use, see box below.) The billing manager sent the letter to the representative by certified mail, along with a cover letter from him reiterating the conversation he had with the rep. Its important to follow up with a letter, says Fernandes. Thats because at Medicare, good people get promoted up and out of the reach of the provider. You need to have a record.

He also keeps a copy of the letter in a file called Medicare correspondence, and he attaches a copy of the postal receipt, showing that the letter was signed for, to his copy of the letter.

Especially with correspondence, believes Fernandes, you need to save all correspondence not because the Medicare representative (or commercial HMO or Blue Cross/Blue Shield representative) is incompetent, he says, but because you will need it in the future. Youre reinforcing a conversation you had, so two years down the line, when the doctor says, Hey, were being audited for doing too many extended ophthalmoscopies, you can say, I had a conversation with the representative, and she said it was okay as long as we showed medical necessity. If you dont have the letter, and only have a memory of that conversation, you could be in trouble, Fernandes notes.

Hatsy Campbell, office manager for Retina Consultants PC, a five-ophthalmologist practice in Hartford, CT, agrees. When we start getting brought up before an HMO or Medicare or the Blues for doing too many 92225s, we write a letter explaining that we are retinal specialists, she says. And we insist that if we are going to be compared to anyone, we be compared to other retinal specialists.

So far, she says, this letter has worked. In fact, she has sent the letter so many times that if a denial ever comes through, she just calls the rep and begins her speech about being a retinal specialist, and then the rep remembers all the letters and the claim is paid.

Get Paid for Both a Consultation and 92225

Ophthalmology Coding Alert has received several letters from readers stating that some providers are questioning whether they should pay for a consultation as well as extended ophthalmoscopy. But both retina specialists we talked to do bill consultations as well as 92225, and get paid for them. Why not? asks Fernandes. Providing that you stay within the CPT guidelines, why couldnt you bill a consult and 92225?

Tip: One of the guidelines is medical necessity, but another very important one is the prohibition against double billing for the same service. If the documentation shows history, visual acuity, slit lamp exam, dilation and then drawing, the physician must decide whether he or she will bill the drawing separately or include it in the level of code selected. If billed separately, the ophthalmologist could mentally cover up the drawing and look at whats left over in the history, exam and medical decision-making in order to select an appropriate level for a consult or a visit. In some cases, a level four or five may still be appropriate, but in many casesespecially for subsequent extended ophthalmoscopya lower-level code should be used.

Campbell often bills a consultation. However, the examination is done before the extended ophthalmoscopy, and sometimes there is no finding that falls within the medical-necessity guidelinesin other words, no diagnosis that matches those which Medicare allows for 92225. In this case, 92225 is considered routine ophthalmoscopy, which CPT says is included in the visit or consult. Retinal specialists normally dont have a problem billing this, because usually the patient has a retinal problem, says Campbell. But general ophthalmologists may have more difficulty getting paid for 92225 and a consult.

In fact, we talked to a general ophthalmologist who does extended ophthalmoscopies, but who doesnt bill for consultations because we dont want to go that high, says Ginger Hudnall, insurance supervisor for the Southern Eye Institute, a two-ophthalmologist practice in Jacksonville, FL.

We bill for an office visit along with the 92225, says Hudnall. And we always have a valid diagnosis to justify medical necessity. There is no problem getting paid for an office visit and the extended ophthalmoscopy, even if it is bilateral, providing that the medical necessity is in both eyes, she adds.

Tip: In general, Medicare is the only payer which allows 100 percent of its fee schedule for each eye when medically necessary to do on each eye. This is a 200 percent payment allowance. Other payers do not typically follow Medicare on this one and most often pay one fee allowance which includes both eyes, or alternatively deny the EOB as being bundled in the visit or consult code billed.