From time to time, we are reminded that we need continued attention to proper documentation and medical necessity requirements for extended ophthalmoscopy. While not new, one Local Coverage Determination (LCD) from First Coast Service Options, Inc. (FCSO), the Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands, spells out the requirements for 92225 and 92226 in detail. Most other MACs also have policies, but we found the FCSO LCD to be particularly succinct.

Q. What does the LCD say?

A. The LCD states, “Extended ophthalmoscopy is an assessment of the posterior segment of the eye (vitreous, retina, optic disc, choroids, etc.) with the pupil dilated using indirect ophthalmoscopy or slit lamp biomicroscopy. These techniques employ an additional diagnostic tool (eg, 3-mirror lens, 20-diopter lens, 90-diopter lens, scleral depression) and include a detailed drawing of the retina. Extended ophthalmoscopy provides a high-intensity illumination, stereoscopic, wide field of view of the ocular fundus for detection and/or evaluation of the vitreoretinal pathology.

“Extended ophthalmoscopy codes are reserved for the meticulous evaluation of the eye in detailed documentation of a severe ophthalmologic problem needing continued follow-up, which cannot be sufficiently evaluated by photography.

“In all instances extended ophthalmoscopy must be medically necessary. It must add information not available from the standard evaluation services and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means.”

The LCD goes on to list a number of conditions where extended ophthalmoscopy is considered medically necessary. In brief, they include the following (not a complete list):

• Malignant neoplasm of the retina or choroid
• Retained (old) intraocular foreign body
• Retinal hemorrhage, edema, ischemia, exudates, and deposits
• Retinal detachment with or without retinal defect
• Retinal defects without retinal detachment
• Diabetic retinopathy, retinal vascular occlusion, or separation of the retinal layers
• Chorioretinitis, chorioretinal scars or degeneration, dystrophies, hemorrhage and rupture, or detachment
• Posterior scleritis
• Signs and symptoms of endophthalmitis
• Retinoschisis and retinal cysts
• Degenerative disorders of the globe

Interestingly, the list describes clinical signs for many of the conditions. For example, diabetic retinopathy includes this description: “This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation.” These descriptions may be obvious to the ophthalmologist, but can be a useful teaching tool for staff.

Q. What documentation is required?

A. The LCD states, “Medical record documentation (eg, office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the extended ophthalmoscopy exam. The medical records must include the following:

• The complaint or symptomatology necessitating the extended ophthalmoscopy exam
• Notation that the eye examined was dilated and the drug used
• The method of examination (eg, lens, instrument used)
• A detailed drawing of the retina showing anatomy in the patient as seen at time of examination, including the pathology found and a legible narrative report of the findings
• An assessment of the change from previous examinations when performing follow-up services (92226)

“If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the ophthalmoscopy exam results and interpretation, along with copies of the ordering/referring physician’s order for the ophthalmoscopy. The physician must state the clinical indication/medical necessity for the ophthalmoscopy in the order for the exam.

• “Documentation in the medical record for a diagnosis of glaucoma must include all of the following:
• A detailed drawing of the optic nerve,
• Documentation of cupping, disc rim, pallor, and slope, and
• Documentation of any surrounding pathology around the optic nerve.”

Q. Where can we find this LCD?

A. LCD #L34017 was effective Oct. 1, 2017. The document is accessible by searching by ID number at the Centers for Medicare & Medicaid Services website at https://www.cms.gov/medicare-coverage-database . It is very important that you regularly check your own MAC’s LCDs, because they can change without notice.

Q. What else should we be thinking of?

A. Documentation requirements in this LCD do not specify a minimum size for the drawing. Those LCDs that do specify a size generally require a minimum of 2.5 to 3 inches; it is likely difficult to include enough detail in a smaller drawing. The drawing should be scaled to depict relative size of the elements, individual for each eye, and clearly separate from the eye exam documentation. Many policies also specify that the drawing not have any preprinted anatomical elements (eg, optic nerve, vascular arcades).

This LCD also does not discuss colored drawings; another policy, from Aetna, includes “Colored using classical representations (red for hemorrhage, blue for detachment, etc.).”¹

Extended ophthalmoscopy is bundled with most retinal surgery codes under Medicare’s National Correct Coding Initiative (NCCI) edits. Finally, many policies indicate that if extended ophthalmoscopy is performed along with other tests (eg, SCODI, FP, FA), it must provide additional, not duplicative, information. RP

REFERENCE

1. Aetna. Extended ophthalmoscopy. Policy Number 0767. Last revised March 1, 2019.