Coding and documentation requirements for extended ophthalmoscopy (EO) changed in 2020. We continue to receive questions about proper use of these tests, and we see increasing issues in payer audits of retinal specialists.

Q. What is extended ophthalmoscopy?

A. EO is a detailed examination and drawing of the fundus, beyond the standard fundoscopy of an eye exam. As of January 1, 2020, EO CPT codes are defined as follows:

• 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
• 92202: Ophthalmoscopy, extended, with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral

Q. What is the difference between codes 92201 and 92202?

A. CPT 92201 describes an examination and drawing of conditions in the peripheral retina performed on one or both eyes, with scleral depression. CPT 92202 pertains to an examination and drawing of conditions of the posterior pole: macula and optic nerve. There is no longer a distinction between initial and subsequent EO.

Q. What diagnoses support the use of 92201 and 92202?

A. EO is indicated for serious retinal pathology. Repeat drawings are warranted by observed changes. Payers are likely to limit the supportive diagnoses based on where the pathology presents and the nature of the drawing: optic nerve or macula vs peripheral retina.

Q. What documentation is required in the medical chart to support EO?

A. Documentation for EO must be above and beyond the exam notes pertaining to the fundus. A detailed retinal drawing is required.

Although payer policies differ, some common charting requirements include the following:

• Documentation must be legible
• Retinal drawing must be maintained in the patient’s record
• Drawings should include sufficient detail, standard colors, and appropriate labels
• Individual for each eye
• Separate and distinct from the eye exam
• An assessment of the change from prior exams when performing follow-up services

Other requirements may also include the following:

• Scaled to depict relative size
• Colored using classical representations (red for hemorrhage, blue for detachment, etc.)
• Notation that the eye was dilated and the drug used

For 92201, you must indicate that scleral depression was used. Draw peripheral retinal abnormalities and include normal anatomy, as well.

For 92202, attend to the optic nerve or macula. Include:

• Detailed drawing of the optic nerve
• Documentation of cupping, disc rim, pallor, and slope
• Documentation of any surrounding pathology around the optic nerve

CPT 2022, Professional Edition, includes sample drawings and notations for these codes. This column, from February 2020, includes additional sample drawings (https://www.retinalphysician.com/issues/2020/special-edition-2020/coding-q-amp;a-eo-codes-at-last-get-a-revamp ).

Q. How large do the retinal drawings need to be?

A. Traditionally, policies simply state that the drawing must be “detailed”. When size requirements are included, they are usually a minimum of 3 to 4 inches in diameter for each drawing. We believe it is difficult to provide sufficient detail in a smaller drawing.

Q. If binocular indirect ophthalmoscopy (BIO) of the fundus is normal, may we claim 92201 or 92202?

A. No. The basis for reimbursement is serious pathology, along with detailed retinal drawing of the pathology. There is no need to draw what is observed in a normal retinal exam; it can adequately be described in the office visit template. Reimbursement for routine BIO is part of an eye examination and EO should not be billed.

Q. What does Medicare allow for 92201 and 92202?

A. These codes are defined as “unilateral or bilateral,” so a single claim is submitted whether one or both eyes are drawn. The 2022 national Medicare Physician Fee Schedule allowable for participating providers is $25 for 92201 and $16 for 92202.

These amounts are adjusted by local wage indices in each area. Other payers set their own rates, which may differ significantly from the Medicare fee schedule.

Q. What are common problems with EO in payer audits?

A. Based on Corcoran Consulting Group’s experience in audits of clients, these are the biggest issues.

Billing EO with other services. CPT instructs, “Do not report 99201, 92202 in conjunction with 92250.” Many policies state that, if EO is performed along with other tests (eg, SCODI, FA), it must provide additional, not duplicative, information.

EO is bundled under Medicare’s NCCI edits with most retinal surgery procedures. Check the edits, which may change quarterly. Many policies also exclude EO during the global period of retinal surgery unless for unrelated conditions.

Drawings are repeated and unchanged. Do not copy previous EO electronic drawings. The retinal drawing should be specific to the patient on the date of the examination, with an interpretation and report to warrant reimbursement. RP