The CPT codes identifying extended ophthalmoscopy (EO), 92225 and 92226, have remained unchanged for decades. In 2020, these codes have at last been deleted, and 2 new codes, 92201 and 92202, have taken their place. Because utilization of the old codes was high, this change is significant for ophthalmologists, including (or particularly) retinal specialists.

DELETED CODES

To allow for easy comparison with the new codes, let’s review what we know about the previous ones. The EO codes you are familiar with are defined as follows:

• 92225: “Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial”
• 92226: “Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent”
• The key difference between the codes is timing: initial or subsequent. Documentation required a retinal drawing. They were identified as unilateral codes; each eye was billed separately. Medicare reimbursement was based on 100% of the allowed amount for each eye. In 2019, the national Medicare allowed amounts were $28 and $26 per eye, respectively.

NEW CPT CODES

The new codes rely on anatomy for differentiation. The first new CPT code is 92201: “Ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.”

Because CPT code 92201 reports peripheral retinal drawings, you can expect the list of valid indications to include conditions of the peripheral retina and vessels rather than disease in the center of the fundus or near the optic nerve. Code 92201 requires scleral depression, and your chart documentation should say so.

The second new code is 92202: “Ophthalmoscopy, extended, with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.” Code 92202 is reported for drawings of the central retina and/or optic nerve. Sufficient view of this anatomy can be accomplished without scleral depression, so it is not an explicit requirement.

REIMBURSEMENT REDUCTION

Similar to other ophthalmic tests such as OCT, fundus photography, and angiography, these new CPT codes are described as “unilateral or bilateral.” This results in a substantial reduction in the Medicare payment, because the 2020 Medicare Physician Fee Schedule allows $26 and $16 respectively — less than half of what the service reimbursed in 2019 when performed bilaterally.

INDICATIONS FOR EO

Indications for EO include the presence of, or progression of, serious retinal disease that merits this detailed exam. The Local Coverage Determination (LCD) #L33476 from Palmetto GBA says the following about EO coded with 92225 or 92226:

“It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. … All findings and a plan of action should be documented in the patient’s medical record supporting the medical necessity for the test(s).” The policy also states that unless there is a change in signs, symptoms, or condition, repeated EO at each visit “may be denied as not medically necessary.” There is no reason to believe the instruction will be very different for the new codes.

DOCUMENTATION

As noted above, detailed drawings are required. Again, referring to prior LCDs, drawings are expected to be of a sufficient size to show adequate detail; we believe they must be at least 2.5 to 3 inches. Examples of suitable drawings are shown in Figures 1 and 2 (not to scale for this publication).

When coding the higher-level evaluation and management (E/M) codes or comprehensive eye exam codes, ophthalmoscopy is included as a required element. Documentation for EO should be above and beyond the exam notes pertaining to the retina; retinal drawing is a necessary component of the documentation. Although Medicare Administrative Contractors’ policies differ, some charting requirements are common:

• Documentation must be legible;
• Retinal drawing must be maintained in the patient’s record; and
• Drawings should include sufficient detail, standard colors, and appropriate labels.
• Documentation of the subsequent service should include evidence of a change (eg, worsening or progression) that warrants it.

In addition, when EO is billed for a diagnosis of glaucoma, documentation in the patient’s medical record 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.

Once again, these are policies pertinent to the deleted codes, but we fully expect instructions to be similar.

NCCI EDITS AND CODING BUNDLES

CPT instructs that 92201 and 92202 should not be billed with fundus photography (92250). Medicare’s National Correct Coding Initiative edits agree, and they also show the codes as mutually exclusive with one another (Table 1). Like the old EO codes, 92201 and 92202 are bundled with most retinal surgery codes.

As of the end of 2019, the CMS Coverage Database contains EO policies for 92225 and 92226 by Palmetto GBA (https://tinyurl.com/w2oo3dc ), National Government Services (NGS; https://tinyurl.com/uknr7hz ), CGS Medicare (https://tinyurl.com/rxxvy5e ), and First Coast Service Options (https://tinyurl.com/vb45bvh ). The NGS LCD has the following to say regarding coverage for EO when performed following retina surgery or in conjunction with other tests:

An EO performed during the global surgery period of an ophthalmic surgery procedure by the same provider who performed that surgery “will not be separately payable unless unrelated to the condition for which the surgery was performed.”

In the event other ophthalmic tests such as fundus photography, fluorescein angiography, ultrasound, and OCT have been performed, EO 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.”

CONCLUSION

The coding change for EO is momentous. It also represents a significant change in Medicare reimbursement. New instructions can be expected for the new codes and will likely be similar to those for the old codes. RP

Editor’s note: This article is part of a special edition of Retinal Physician that was supported by REGENXBIO.