Optometry Coding & Billing Alert

Use 362.81 to get paid for 92225

If you are linking ophthalmoscopy procedures to a diagnosis of hypertension or diabetes, you may receive unwarranted denials.

Instead, report diagnosis codes for the patients' signs and symptoms to ensure reimbursement when dealing with ocular manifestations of a disease outside of optometry's scope, such as diabetes and hypertension.

The difficulty arises when optometrists try to link ophthalmoscopy tests such as 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) to medical diagnoses not appropriate to their practices, says David Gibson, OD, FAAO, of Lubbock, Texas.

"I'm an optometrist, not an endocrinologist," Gibson says. "I may establish the presence of a diagnosis of diabetes in the case history and document the fact that certain signs of the disease are present, but I did not make the diagnosis of diabetes."

Opt for 362.81 Over 250.xx

"What we can diagnose is the bleeding of the retina and the changes that are consistent with a known type of diabetes," Gibson says.

"Retinal hemorrhage (362.81) is one possible diagnosis; however, retinal hemorrhage(s) in the presence of diabetes in the case history will probably be classified as diabetic retinopathy (362.01, Background diabetic retinopathy; or 362.02, Proliferative diabetic retinopathy) depending on your actual observation," Gibson says.

Wrong way. For example, a patient presents with blurred vision, and the optometrist performs a bilateral ophthalmoscopy. The patient tells you she is diabetic, so you submit a claim using diagnosis code 250.03 (Diabetes mellitus without mention of complication; type I [insulin dependent type], [juvenile type], uncontrolled) and link it to both 92225-RT (Right side) and 92225-LT (Left side). The patient's insurance carrier denied the claim twice stating the combination of procedure code and diagnosis code is invalid.

Right way. Even if the patient was referred by a primary-care physician (PCP) who diagnosed diabetes, you need to report an appropriate ICD-9 code such as 362.81 to represent the patient's signs and symptoms, not a code for the type of diabetes. 

Only the MD or DO who diagnosed the disease should report a diagnosis code from the 250 series.

Don't Stress Over Hypertension Codes

If you've ever tried to link an ophthalmoscopy to a diagnosis of hypertension and had the claim rejected, you're not alone.

"We used to use the hypertension code for a patient and get paid for it," says Sue Sullivan, an optometry office manager in the Cleveland area. But not anymore: Hypertension, like diabetes, is outside of the optometrist's area of expertise.

Most patients with retinopathy related to hypertension or diabetes are visually asymptomatic, although they may occasionally present with decreased vision (368.8). 

The optometrist may see narrowing of the vessels in the retina (see the 362.1x range), retinal hemorrhages (362.81) and other signs of retinopathy including occlusion and swelling (362.30-362.37). These are all appropriate symptom codes you should link to ophthalmoscopies. For retinopathy that is related to hypertension, use 362.11 (Hypertensive retinopathy), even if another physician referred the patient with a diagnosis of hypertension (401).

While optometrists perform a large portion of ophthalmoscopies for referred patients, you can never bill Medicare for these services with a diagnosis of diabetes or hypertension.

You may have the option of using a consultation code (99241-99245), but don't forget that these codes have specific documentation requirements.