CODING Q&A

EO’s Frequency Means More Scrutiny

BY SUZANNE CORCORAN, COE

Extended ophthalmoscopy (EO), a useful tool when dealing with serious posterior segment disease, is a commonly performed service within the Medicare system. In CY 2012, it occurred in 18% of all eye examinations ophthalmologists performed on Medicare beneficiaries. Only scanning computerized ophthalmic diagnostic imaging of the retina (CPT 92134) occurs more often — in 19% of all eye exams. Consequently, it’s important to understand what is needed to warrant reimbursement and ensure that you will prevail during post-payment scrutiny.

THE NUTS AND BOLTS OF EO

Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy of an office visit. It is identified in CPT as 92225 (Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial) and 92226 (subsequent). CPT goes on to state:

92225 pertains to the initial evaluation of a disease, while 92226 involves the repeated, or subsequent, evaluation of the same problem made worse by progression of the underlying pathology. Sometimes 92225 may be used more than once per eye. Even though 92225 has been performed on an eye, it is possible to do another initial EO for a new condition.

EO is indicated for a large number of conditions involving posterior segment pathology when the extent of the examination is greater than that required for a routine ophthalmoscopy. It is reserved for serious retinal pathology such as retinal tears and retinal detachment. The practice should not bill it in every instance where you use an indirect ophthalmoscope and make a note about the fundus. Most Medicare administrative contractors (MACs) have published local coverage determination (LCD) policies, which include a list of covered diagnoses.

APPROACHING UPPER LEVELS

When coding the higher-level E/M codes (992x4, 992x5) or comprehensive eye codes (920x4), ophthalmoscopy is a required element of the eye exam. The chart notes for this routine ophthalmoscopy can take many forms: descriptive terms, quantitative measures of cup-to-disk ratio, or small sparse sketch of the fundus. A retinal drawing for EO is much more detailed, larger, commonly colored, carefully annotated, and appropriate for the serious condition depicted.

Although each MAC’s published policies contain specific documentation requirements, some points are common throughout, including:

• legible documentation;

• retinal drawing must be maintained in the patient’s record; and

• drawings should include sufficient detail, standard color(s), and appropriate labels.

The utility of the retinal drawing is apparent when the patient returns for re-evaluation of the same condition. The ophthalmologist can compare what he observes today with the prior retinal drawing. Where the change is clinically significant, the physician should make another retinal drawing to serve as a new benchmark for future comparison. If no apparent change is noted then another duplicative retinal drawing is not needed or justified. The new drawing that reflects the clinically significant change is the support for a subsequent EO (92226).

Most LCDs don’t specify the size of the drawing, but simply state that the drawing must be “detailed.” Some LCDs do include size requirements, usually 2.5-3 inches or more. Experience teaches us that it is difficult to supply sufficient detail in a smaller drawing. Implicit in this requirement for EO is that the drawing cannot represent a normal fundus no matter how thorough the ophthalmoscopy.

BILLING DETAILS

In CPT, EO is defined as a unilateral test so reimbursement is per eye. Due to this definition, payers assume that the service is not always needed on both eyes and will not always be billed as a bilateral service. In 2014, the national Medicare allowable is $27.94 per eye for the initial exam (92225) and $25.08 per eye for the subsequent exam (92226). These amounts are adjusted by local wage indices in each area. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

At present, CMS bundles EO with most retinal surgery codes under the National Correct Coding Initiative (NCCI); in addition, the two codes are mutually exclusive with one another. Some LCDs also state that EO is not payable on the same day as OCT (92133,92134), and a few payers also bundle EO with fundus photography.

We infer that EO and imaging studies performed concurrently on the same eye which contain the same information are redundant and that practices should bill only the more intensive service.

Considerable regional differences exist in the frequency of this service, but in every region of the country, it is flagged as an over-utilized service and subject to frequent Medicare audits. In a retinal practice, it is likely that EO will occur more often than the norm and attract added scrutiny. By paying attention to the quality of the retinal drawings as well as the severity and progression of the disease shown, you can prevail in a challenge to your utilization pattern for EO. RP