Ophthalmology and Optometry Coding Alert

Question: Is extended ophthalmoscopy (EO) included in a general ophthalmic examination or can we report it separately? Also, when is it acceptable to report EO bilaterally?

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Answer: Any general ophthalmic examination will include a routine ophthalmoscopy, but an extended ophthalmoscopy is a special ophthalmologic service that goes beyond the general eye exam.

When an initial exam uncovers a serious retinal problem, retinal specialists then turn to extended ophthalmoscopy (92225,  Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial; and 92226, ... subsequent) for a more detailed examination.

There are no Correct Coding Initiative (CCI) edits in place that prevent you from reporting both the EO and the routine eye exam codes together, so you can report both services as long as the documentation supports it.

While you're unable to report most of the other ophthalmic testing codes in the 92xxx series bilaterally, you can report 92225 and 92226 for each eye – if there is a medically necessary reason - because EO is an inherently unilateral procedure. Therefore, use either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) to reflect bilateral services. Your payer will drive your choice in modifiers billed.

Remember, if the physician doesn't find an anomaly, doesn't draw and label any anomalies that are found, or if there isn't an interpretation and report, you should not bill for the EO. Some payers also limit the number of EOs that can be billed each year, depending on the condition being reported. When billing 92226 (subsequent), be sure there have been changes in the patient's signs, symptoms or condition, or your payer may deny the service as not medically necessary. And finally, an extended ophthalmoscopy in the postoperative period of an ophthalmologic surgery will typically not be covered when billed by the same physician that performed the surgery unless it is unrelated to the surgical procedure that prompted the global period.