Ophthalmology and Optometry Coding Alert

Question: For a recent visit, the ophthalmologist’s notes read:

Procedure: Examination under anesthesia, ERG, OCT, RetCam, and cycloplegic refraction.

Indications: Vision loss, right eye.

Patient underwent induction of general anesthesia, just after induction intraocular pressures were measured with the Tono-Pen 18, 17 right eye, and 19, 19, left eye. An endotracheal tube was placed. Cycloplegic refraction of -14.50, +2, axis 90 right eye, and -15.00, +2, axis 90, left eye. The patient had been light adapted a full/ERG and 30 Hz flicker ERG were  performed. This was very attenuated almost non-recordable right eye. A 30 Hz  flicker was noted, left eye. OCT was performed, indicating probable posterior  staphyloma, right eye. RetCam photos were then performed.

How should I code for this?

Codify user

Answer: You should be able to report the following:

·         92275 (Electroretinography with interpretation and report) for the ERG

·         92018 (Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete ) for the exam under anesthesia

·         92250 (Fundus photography with interpretation and report) for the RetCam photos

·         92015 (Determination of refractive state) for the refraction — but note that Medicare will not reimburse for this code.

The OCT (92133, Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) is bundled with 92015 and has a lower RVU value, so you should only report 92015 in this case.