CODING CORNER

Common Myths When Billing Extended Ophthalmoscopy

BY JOY WOODKE, COE, OCS

Extended ophthalmoscopy (EO) is a necessary function in the retina practice. Often, the correct coding and documentation requirements are misunderstood for these services. Some of these misconceptions can lead to inappropriate billing and deficient documentation.

Myth #1 The definition of initial and subsequent ophthalmoscopy is based on whether the patient is new or established. The appropriate use of CPT code 92225 (extended ophthalmoscopy, initial) is for the examination and documentation of a new event or diagnosis. CPT Code 92226 (extended ophthalmoscopy, subsequent) is used when a change in a chronic condition or pathology is determined and drawn.

For example, during a new patient examination an EO is performed and documented with a diagnosis of wet macular degeneration in the right eye. Coding for this encounter is 92225-RT. The next month, the patient is evaluated and the disease has progressed. An EO is performed and the progression of the condition is documented, and a 92226-RT is billed. Six months later, the same patient is seen for sudden decreased vision and floaters, which is diagnosed as a retinal tear in the right eye. EO is completed. Because this encounter is for a new event, it would be appropriate to bill 92225.

Myth #2 The drawing is the only documentation requirement for extended ophthalmoscopy. Along with a detailed drawing that includes findings and labels, EO documentation should include the specific method of examination (e.g. 360˚ scleral depression, 90D lens, or fundus contact lens), an interpretation and report describing all findings and a plan of action, and the medical necessity for the service.

Myth #3 Ophthalmoscopy is inherently bilateral and can only be billed once per session. When pathology is present in both eyes and it is medically necessary to document with EO, 92225 or 92226 is payable per eye. Adding the HCPCS modifiers -RT and -LT would be appropriate to identify laterality. Reimbursement for bilateral ophthalmoscopy would be 100% per eye.

Myth #4 Billing for routine direct and/or indirect ophthalmoscopy is appropriate as long as the drawing is completed. Routine ophthalmoscopy is included in the appropriate level of office visit code whether E/M (99XXX) or Eye code (92XXX) and should not be reported separately. The definition of EO is a more extensive examination that requires a detailed and labeled drawing that can’t be documented in any other way.

Myth #5 The drawing for ophthalmoscopy must be in color. Although many retina specialists may prefer a color drawing for EO, this is not a documentation requirement for most payers. A drawing that is clearly identified and labeled and appropriately represents the retinal pathology is required. Some carrier policies require the drawing to be a minimum of 4 inches in diameter. I recommend a review of your local Medicare Administrative Contractor (MAC)* and commercial carrier policies for these specifications.

Myth #6 It is appropriate to document the drawing for ophthalmoscopy from the OCT findings. The definition for ophthalmoscopy is more extensive than a routine direct or indirect examination that includes other diagnostic techniques defined as lens, scleral depression or other instruments. Reviewing the OCT images in lieu of the extensive EO examination would not be appropriate. Additionally, the OCT provides an image documenting the pathology present and duplicating by drawing the findings could be seen as unnecessary.

COMMIT TO THE PROCESS

Although misconceptions can be common, identifying proper coding principals is recommended for any ophthalmic practice. With the scrutiny surrounding coding and reimbursement in a retina practice, commitment to this process is essential. With the frequency of billing for EO, careful attention to the definition and policies for this service will ensure proper reimbursement, and hopefully avoid unnecessary audits. NRP

Ms. Woodke is an administrator with Oregon Eye Consultants, LLC.