Coding Q&A

Update on extended ophthalmoscopy


Update on Extended Ophthalmoscopy


Extended ophthalmoscopy continues to be among the most heavily audited codes in ophthalmology — and with good reason. From my experience, there are very few audits that I conduct on retinal practices where the parameters for documentation guidelines and compliance are in order when billing this physician service. The Medicare contractors/carriers are well aware of this and, nationally, there has been a rash of updates on the Local Coverage Determinations (LCDs) regulating this.

One of the most lucid of these policies is that of National Government Services/Empire Medicare of New Jersey, and this article is based on those policies as reference material. The revised guidelines will be in effect as of December 2007 and may be viewed on their website at that time ( If you are in compliance with this policy, you probably will be in compliance with any other.


92225. Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report, initial

92226. Subsequent

The initial ophthalmoscopy code should be used for new patients or consultations or if a new consultation is requested for a different condition. The subsequent ophthalmoscopy code should be used for all follow-up examinations and document an assessment of the change from previous examinations.

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

Inherent in the description is the mandate that a retinal drawing is part of the chart documentation (specific requirements found in LCDs) and an interpretation and report also be included. Without the drawing, the service is considered routine ophthalmoscopy.


This varies with each contractor/carrier. Empire's is among the more stringent. Follow it and you will never be faulted. Without the proper drawing, your claim will be denied because it will be considered merely part of the general examination. If your drawing is considered a sketch without enough detail, in addition to the denial, you will repay under audit, possibly with penalties.

► Diameter: 3 to 4 inches

► All items must be identified and labeled

► Colors: 4 to 6 standard colors although clearly labeled noncolored drawings are acceptable

► The drawing should be anatomically specific to that patient and should represent normal, abnormal, and common findings (eg, retinal detachments, hypertensive changes, proliferative diabetic retinopathy, lattice degeneration)


Diagnosis. As with most LCDs, there is a list of acceptable diagnoses for the given service and it is these diagnoses that form the foundation for medical necessity. If the diagnosis billed does not correlate with the diagnoses listed in the LCD, the claim will be denied.

Screening. If the service is performed as a screening service, it is not covered by Medicare.

Fellow Eye. Empire Medicare states that extended ophthalmoscopy of a fellow eye without documented signs and symptoms or new abnormalities on general ophthalmoscopic examination will be denied as not medically necessary.

Subsequent Ophthalmoscopy. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms, or condition may be denied as not medically necessary.

Routine Ophthalmoscopy vs Extended Ophthalmoscopy. If you are coding for extended ophthalmoscopy in addition to an E/M (Evaluation/Management) level 4 or higher examination, you must document routine ophthalmoscopy examination of the optic disc and posterior segment so that you have performed and documented 14 elements. If you go right to extended ophthalmoscopy, then you cannot bill higher than level 3.

Cigna Medicare (North Carolina) states, "Frequency for providing these services depends upon the medical necessity in each patient and this, of course, relates to the diagnosis. A serious retinal condition must exist, or be suspected, based on routine ophthalmoscopy and require further detailed study."

Multiple Diagnostic Tests. The Empire Medicare policy explicitly states that when performing multiple diagnostic tests there needs to be a reasonable medical expectation that the multiple imaging services might provide additive information and not duplicate information obtained by the other tests. Otherwise, the extended ophthalmoscopy will be denied as not medically necessary.


A drawing, even a beautifully drawn, labeled, and detailed drawing, absolutely does not qualify for payment for extended ophthalmoscopy unless there is an interpretation and report.

Here's what needs to be included:

Clinical Findings. The interpretation and report should succinctly summarize your clinical findings. It does not have to be lengthy — just the pertinent findings. It should not be scribbled within the body of the examination where it looks like part of the examination. Auditors will miss it and you will be challenged.

Comparative Data. Medicare always likes to know if something is better, worse, or just the same as before. And this is true for interpretation and report requirements. If a hemorrhage has resolved, visual field loss has progressed, or a lesion size has changed, then these findings need to be noted. When coding for subsequent extended ophthalmoscopy be sure to note the change, if any, from the prior examination.

Clinical Management. Documenting the effect of the diagnostic test on your clinical management is the area that is almost always lacking in the interpretation and report. Medicare wants to know why it is paying you extra for this test — this extended ophthalmoscopy, this OCT, this fundus photo. You must address how this is going to help you or affect your clinical management. Are you going to change/increase/stop medications? Are you going to recommend surgery? Are you suggesting further diagnostic testing? The answer to the pertinent question needs to be part of your written report.

Without the report, the service will be denied as not medically necessary. In addition, be sure to document a plan of action in your chart notes.


How often can you bill for extended ophthalmoscopy? Are the rules different when the patient is in a global period? Important questions have difficult answers.

Here are the guidelines from Empire (open your ICD-9 book):

► "Patients actively being treated with intravitreal injections of medication for exudative AMD (ICD-9-CM code 362.52) may require up to 12 extended ophthalmoscopies per eye, per year.

► Conditions coded with other ICD-9-CM codes in the range 360.0-365.9, may require up to 6 extended ophthalmoscopic examinations per eye, per year.

► For ICD-9-CM codes 190.0, 190.5, 190.6, 198.89, 224.5, and 224.6, up to 4 extended ophthalmoscopic examinations may be required per eye, per year. Other conditions usually require no more than 2 extended ophthalmoscopic examinations per eye, per year."

► Extended ophthalmoscopy is a physician service (examination of the eye) commonly occurring during the global postoperative period of ophthalmic surgery. As a physician service, it is included in the aftercare of the patient and is not separately billable.

► Services billed in excess of these utilization guidelines will be denied."


Instrumentation. Be sure to indicate whether an indirect lens or contact lens biomicroscopy was used,

Dilating drops. Be sure to document which eye(s) and which drop(s) were used,

Modifier usage. If you are performing extended ophthalmoscopy in a global period for an unrelated condition, append modifier 79 to assure payment. Because it is a physician service, do not try to break it down into professional and technical components (modifiers 26 and TC). Because the codes are unilateral, you must append a site modifier (RT, LT, or 50).

Code correlation. Be sure to use subsequent ophthalmoscopy (92226) with follow-up office visits.

Code correspondence. The service can be billed with both E/M and Eye codes.

New patient status. If the patient has not been seen in a face-to-face encounter by any physician member of the practice for 3 years, it would be appropriate to bill 92225.


This may seem like a lot of work, but it's really a matter of proper chart documentation in order to be in compliance. Some physicians prefer not to do the extensive drawing and interpretation and report — and that is your choice. Just don't bill for the service. RP