Extended ophthalmoscopy (EO; CPT 92225, 92226) and imaging of the retina (CPT 92250, 92134, 92235, 92240) are overlapping services. This overlap often leads to biller confusion as to whether both may be reimbursed when performed concurrently. When EO and imaging are performed concurrently, reimbursement depends on these tests finding different information.

Q. Is there medical necessity?

A. Imaging and retinal drawings are valuable tools for assessing the posterior pole. When these tests are performed in tandem, justification for reimbursement depends on finding different information in the drawings and images.

Billing EO in conjunction with other imaging is permissible only when medically necessary. Medical necessity depends on whether EO is duplicative with imaging. Through our chart reviews and the audits of payers, we find that EO is often (but not always) duplicative with imaging and, therefore, should not be billed.

Some Medicare Administrative Contractors (MACs) have addressed billing EO in conjunction with other imaging. According to CGS Administrators, a MAC for a number of states, determination of medical necessity is contingent upon finding “… a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.”¹

National Government Services, another MAC, reaffirms this standard and states, “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.”²

Q. What is “additive information?”

A. The most recent First Coast Service Options LCD says that additive information is “… information not available from the standard evaluation service and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means.”³

Specifically, regarding the issue EO additive information, the same LCD states, “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.”

Q. What should we consider prior to billing?

A. Before billing for multiple tests, consider why each was performed and what information it provides (new or duplicative). Where multiple diagnoses are involved and imaging cannot capture the desired information, a separate charge for EO may be justified. In those cases, documentation should include a unique order for the imaging test(s), retinal drawings for the EO, and a separate 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.

The following example of additive information demonstrates a situation where EO and imaging are both warranted: An established patient returns for re-evaluation of mild, bilateral, dry age-related macular degeneration. At the prior visit, OCT of the retina (92134) was ordered. Prior to dilation, the test is performed today. During your dilated eye exam, you note a suspicious appearance of the peripheral retina in the left eye. Using bilateral indirect ophthalmoscopy with scleral depression, you find a retinal tear without retinal detachment in the left eye; you schedule laser prophylaxis. A retinal drawing for the left eye is entered in the chart. The National Correct Coding Initiative (NCCI) edits do not bundle CPT 92134 with 92225, although many coverage policies specify limitations.

In this case, payment for EO is not duplicative with OCT because peripheral and central retina are distinct and the OCT cannot readily image the periphery; the information is additive.

A second example describes a situation in which EO and imaging are duplicative, and only one is warranted: An established patient returns for re-evaluation of severe, bilateral, open-angle glaucoma. During the dilated eye exam, the ophthalmologist notes an optic disc hemorrhage OS and orders a fundus photograph of the new finding. Additionally, a retinal drawing of the optic nerve for the left eye is entered in the chart. The NCCI edits do not bundle CPT 92250 with 92225, but in this case the drawing and the photograph are duplicative and the information is not additive. Therefore, only bill for one of the tests. RP

REFERENCES

1. CGS Administrators LCD 34399. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34399&ver=19&Date=01%2f01%2f2019&DocID=L34399&SearchType=Advanced&bc=KAAAABAAAAAA& . Accessed August 9, 2019.
2. National Government Services LCD 33567. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=33567&ver=24&Date=01%2f01%2f2019&DocID=L33567&SearchType=Advanced&bc=KAAAABABAAAA& . Accessed August 9, 2019.
3. First Coast Service Options LCD L34017. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=34017&ver=11&DocID=L34017&SearchType=Advanced&bc=IAAAABAAAAAA& . Accessed August 9, 2019.