Extended ophthalmoscopy (EO; CPT 92225, 92226) and retinal imaging (CPT 92250, 92134, 92235, 92240) are overlapping services, so billers ask whether both can be reimbursed when they occur on the same day. Clearly, ophthalmologists would prefer the answer to be “yes,” but payers take a different view — they say, “sometimes.” When EO and imaging are performed concurrently, reimbursement depends on obtaining different information.

MEDICAL NECESSITY

Some Medicare Administrative Contractors (MACs) have addressed billing EO in conjunction with other retinal imaging. The LCDs for both CGS Administrators¹ and National Government Services² state: “When other ophthalmological tests (eg, fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.”

This is also addressed in the LCDs published by CGS,³ Wisconsin Physicians Service Insurance Corporation,⁴ and First Coast Service Options.⁵

Through our chart reviews, as well as the audits of payers, we find that EO is often (but not always) duplicative with imaging and, therefore, should not be billed. The following vignette provides a situation where EO and imaging are both warranted (Figure 1).

A new patient, seen on an emergent basis, describes flashes of light and blurry vision. You find bilateral vitreous degeneration (H43.813) and bilateral lattice degeneration (H35.413). Today’s visit includes the following bilateral tests: fundus photography (FP, 92250), macular SCODI (92134), as well as initial extended ophthalmoscopy to evaluate the PVD and lattice. Interpretations for FP and SCODI-P are noted. Retinal drawings for each eye revealed peripheral lattice degeneration not seen with FP or SCODI-P.

The NCCI edits bundle 92250 with 92134 so 92250 is not billed; 92225 is not bundled with 92250 or 92134 although there are limitations in many coverage policies. The physician’s claim will read as shown in Figure 1. In this case, payment for EO is not duplicative with SCODI-P because peripheral retina is extremely difficult to image with optical coherence tomography.

Before billing for multiple tests, consider why each was performed and what information it provided (new or duplicative). Where multiple diagnoses are involved and photography or SCODI cannot capture the desired information, a separate charge for EO may be justified. In those cases, documentation should include a unique order, the retinal drawings, and an interpretation for each test. Where multiple tests are performed for a single diagnosis or the interpretations read the same for all tests, it is difficult to argue that additive information was obtained.

BUNDLES

The CMS National Correct Coding Initiative (NCCI) edits do not explicitly preclude billing EO with other retinal imaging tests, but existing edits bundle EO with intravitreal injections (CPT 67028). In a few situations, it may be possible to unbundle EO and intravitreal injections. For an illustration of a situation where EO, SCODI, and intravitreal injection are warranted, consider this vignette (Figure 2):

Your patient returns for re-evaluation of early, nonexudative age-related macular degeneration (AMD), right eye (H35.3111) and exudative AMD with active choroidal neovascularization, left eye (H35.3221). Today’s exam includes macular SCODI OU and subsequent extended ophthalmoscopy OU. An interpretation and report is placed in the chart. Retinal drawings for each eye reveal peripheral vasculitis (H35.063) not seen with SCODI-P. After a discussion of risks/benefits/alternatives, the patient receives an intravitreal injection of bevacizumab OS.

Within the NCCI edits, 92226 is bundled with 67028; 92134 is not bundled with 92226 or 67028. The physician’s claim will read as shown in Figure 2. Payment for extended ophthalmoscopy OD is permitted because it was performed in a different eye than the intravitreal injection; modifier XS applies. While non-Medicare payers are not required to adhere to the NCCI edits, most do.

CONCLUSION

More is not always better. Retinal imaging and retinal drawings are valuable tools in assessing the posterior pole; when these tests are performed in tandem, justification for reimbursement depends on obtaining different information from the drawings and images. RP

REFERENCES

1. CGS Administrators LCD 34399. https://tinyurl.com/y7dd57nj . Accessed Feb. 11, 2018.
2. National Government Services LCD 33567. https://tinyurl.com/y8nj852m . Accessed Feb. 10, 2018.
3. CGS Administrators LCD 34061. https://tinyurl.com/yb6uq8sa . Accessed Feb. 10, 2018.
4. WPS LCD L34760. https://tinyurl.com/yaqh6pcn . Accessed Feb. 9, 2018.
5. FCSO LCD L34017. https://tinyurl.com/ybekgj52 . Accessed Feb. 9, 2018.