Coding Q&A

Know When to Use Codes 92225 and 92226


Know When to Use Codes 92225 and 92226


Q. What is the difference between CPT codes 92225 and 92226? Should each follow-up extended ophthalmoscopy be billed as 92226 even if the patient has not been seen for a while? Also, are extended ophthalmoscopy services being denied when performed in the global period? Can we bill these?

A. CPT describes the 2 codes as follows:

► 92225 ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial

► 92226 subsequent

Technically, code 92225 is used for the initial encounter for a disease entity. Subsequent follow-up extended ophthalmoscopies would be coded using CPT code 92226.

However, if the patient had not been examined for a while and presented with new symptoms suggesting a different pathological entity, one could use CPT code 92225 again. In a similar mode, if the physician were asked to do a reconsultation for a different problem, 92225 could be used. In practice — particularly since this is one of the most heavily audited codes in ophthalmology — most ophthalmologists use 92226 for all subsequent extended ophthalmoscopies on the same patient.

Some Medicare carriers have begun issuing Local Coverage Determinations prohibiting extended ophthalmoscopy from being billed in the global period. An example of this is Empire Medicare of New Jersey which includes the following statement: "Extended ophthalmoscopy (codes 92225, 92226) performed during the global surgery period of an ophthalmologic surgery procedure by the same provider doing the surgery will not be separately payable unless unrelated to the condition for which the surgery was performed." The policy is L3624 and can be found under Diagnostic Medical in the Local Coverage Determination List at

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at

You must check with your Medicare carrier to determine what their payment policy is. This is best achieved in writing, preferably from the Carrier Medical Director. This way, you will avoid receiving any misinformation from a telephone inquiry.

Q. I have heard so many conflicting instructions for vital signs requirements at various seminars that now I am totally confused. Can you help?

A. This questions surfaces periodically in reference to various procedures that are performed in an office setting, such as intravitreal injections and various lasers. These regulations do not apply to office-based procedures, but may apply to facility based procedures.

Q. When should I use Category III codes and when should I use unlisted codes? Is payment for Category III codes regulated by Medicare nationally? Category III codes seem to appear more frequently than Category I codes — what's the protocol here?

A. If a Category I code is determined payable by Medicare, it will be paid by all carrier/contractors whereas payment decisions for Category III codes are determined by each carrier/contractor independently.

The general rule is if there is a Category III code, you should use it rather than the CPT unlisted code. However, occasionally there are instances when Medicare will pay for the unlisted code or their own G code until the Category III codes are processed into their payment system.

There also are instances when Medicare has issued a temporary G code that is paid while Medicare transitions payment for a Category III code.

Q. The surgeon removes a scleral buckle. Is it correct to bill 67115?

A. CPT code 67120 (removal of implanted material, posterior segment; extraocular) should be used for coding removal of a scleral buckle. CPT code 67115 (Release of encircling material, posterior segment) is usually used for releasing tension. CPT codes 67120 and 67121 (Removal of implanted material, posterior segment; intraocular) differ in that 67120 is for removal of external (extraocular) devices whereas 67121 is used for removal of intraocular implants in the posterior segment such as silicone oil and displaced intraocular lenses. Remember that retrieval of an IOL from the anterior segment only, using a limbal incision is CPT code 65920 (Removal of implanted material, anterior segment).

CPT codes copyright 2006 American Medical Association. RP