Coding & Reimbursement

Billing for extended ophthalmoscopy

Coding & Reimbursement

Billing for Extended Ophthalmoscopy

By Suzanne L. Corcoran, COE

Extended ophthalmoscopy is a useful tool when dealing with serious posterior segment disease. Medicare rules can be confusing, though, so this month we address this test.

Q. What is extended ophthalmoscopy?

A. Extended ophthalmoscopy (EO) is a detailed examination and drawing of the fundus that goes be yond the standard funduscopy of an office visit. It is identified in CPT as 92225 (Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial) and 92226 (subsequent).

CPT goes on to state, "Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a non-itemized service and is not reported separately."

Code 92225 pertains to the initial evaluation of a disease, while 92226 in volves the repeated, or subsequent, evaluation of the same problem made worse by progression of the underlying pathology. Sometimes 92225 may be used more than once per eye. Even though 92225 has been performed on an eye, it is possible to do another initial EO for a new condition.

EO is indicated for a wide range of posterior segment pathology when the extent of the examination is greater than that required for a routine ophthalmoscopy. It is reserved for serious retinal pathology. Most Medicare administrative contractors (MACs) have published local coverage determination (LCD) policies, each of which includes a unique list of diagnoses.

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

A. When coding the higher level 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. The CPT handbook description includes a retinal drawing as a necessary component of the documentation.

Although each MAC's published policies contain specific documentation requirements, some points are common throughout, including:

► Documentation must be legible.
► Retinal drawing must be maintained in the patient's record.
► Drawings should include sufficient detail, standard color and/or appropriate labels.

Documentation of the subsequent service (92226) should include evidence of a change in the condition (e.g., worsening or progression) that warrants a repeated examination.

Most LCDs don't specify the size of the drawing, but simply state that the drawing must be "detailed." Some LCDs do include size requirements, usually 2.5 to 3 inches. We believe it is difficult to supply sufficient detail in a smaller drawing.

Q. If binocular indirect ophthalmoscopy reveals no findings, may we bill 92225 or 92226?

A. No. The basis for reimbursement is serious pathology along with supporting documentation in the form of a detailed retinal drawing. Reimbursement for the indirect ophthalmoscopy is part of the eye examination in this instance and EO should not be billed in addition to the eye exam.

Q. What is the Medicare allowable for EO?

A. EO is defined as a "unilateral" test so reimbursement is per eye. At the time of this writing, the national Medicare allowable is $24.71 per eye for the initial exam (92225) and $22.12 per eye for the subsequent exam (92226). These amounts are adjusted by local wage indices in each area. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Q. How frequently is this test performed?

A. Medicare utilization rates for claims paid in 2008 show that EO was performed at 15% of all office visits by ophthalmologists. That is, for every 100 exams and consultations performed on Medicare beneficiaries, Medicare paid for this service 15 times. Note that this service is billed per eye and the 15% represents tests rather than patients. For optometrists, the utilization rate is lower.

There are considerable regional differences in the frequency of this test. But in every region of the country, it is flagged as an over-utilized service and subject to frequent Medicare audits. Documentation of the test, and its medical necessity, are even more important for EO than for other services. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or