Optometry Coding & Billing Alert

Question: Can the special ophthalmological services be provided and reported with the general eye codes? Is modifier 25 required on the eye code if the two are performed together?

Colorado Subscriber

Answer: You should definitely report the special ophthalmological services (92015-92140) in addition to the general eye codes (92002-92014) if you use eye codes rather than E/M codes to report office visits. Testing services do not require the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), because they are not considered minor procedures. Minor procedures have a postoperative period of 0 or 10 days and require that modifier 25 be used on the eye code or E/M service when the definition is met.

So if an established patient presents for a comprehensive evaluation of the function of his eye and has an extended ophthalmoscopy, you will need to use 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) and 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial). But be careful of your local medical review policies or payment policies from your carrier.

Caution: Some carriers have a long-time edit in place not to pay for extended ophthalmoscopy (92225-92226) when billed with 92014. If this is the case in your area, you either need to bill the services and end up in the review and appeal process proving medical necessity or must select the intermediate-level eye code or an E/M code instead of the comprehensive eye code.