Coding Q&A

Little-used codes and when to use them


Little-used Codes And When to Use Them


Q. When is E/M Code 99241 ever used? The reimbursement for it seems too small even compared to the lowest eye code 92002.

A. Very few situations call for the use of E/M Code 99241. An example would be examination of an infant when only 1 or 2 examination elements are performed. The intermediate eye code (92002) mandates an external ocular and adnexal examination, which encompasses examination of the eyelids and adnexa as well as a slit lamp examination of the cornea, anterior chamber. iris, and lens.

This question raises a related issue, namely, low-level inpatient consultations (CPT codes 99251-99255).

When doing examinations on infant patients with a diagnosis of retinopathy of prematurity, a low-level examination can and should be performed in addition to the extended ophthalmoscopy. Usually, it is possible to evaluate response to a bright light (vision), lids/adnexa, and gross cornea and sclera in addition to optic nerve and fundus. This encompasses the minimum of 5 elements required for a level 1 inpatient consultation. With a proper drawing, interpretation, and report, you can capture a level 1 consultation plus extended ophthalmoscopy.

Q. We are a retina practice that has, until now, performed fluorescein angiography/fundus photos and OCTs on the same day. We are not paid for the fundus photos or the OCTs. We were wondering how other practices are handling this situation.

A. Only Medicare reimburses for fluorescein angiography and fundus photographs performed on the same day, but not other insurers.

The current procedure code for OCT is 92135 (Scanning Laser Ophthalmic Diagnostic Imaging). This code was developed for glaucoma diagnostic testing. The machines recreated an image of the optic nerve and many practices began billing both the test and fundus photography. Because OCT produces an image of the optic nerve, many practices began billing both OCT and fundus photography even though they were not performing traditional fundus photography. Medicare considered this abusive/fraudulent coding and bundled the 2 codes in the National Correct Coding Initiative. So when you bill 92135 and 92250 together for the same date of service, you are paid for only 1 of them.

When OCT began to be used, the code was adapted by some Medicare carriers/contractors by including the appropriate retinal diagnoses in the Local Coverage Determination. Still, not all carriers/contractors have policies that incorporate the appropriate diagnoses, making it hard to get paid.

So how do you get paid for both tests when performed on the same day? There are certain instances when you may be able to break the bundle. However, a word of caution: You should connect with your Carrier/Contractor Medical Director to confirm that there are diagnoses that would apply.

The National Correct Coding Initiative answered queries on this with the following response: "The edit indicates that the routine use of both techniques on the ipsilateral eye on the same date of service is inappropriate but may be justified in some circumstances. The Medicare carriers define the circumstances in their jurisdictions".

Q. What might be a reason that a surgeon would do a peripheral iridectomy (CPT Code 66625) during a retinal detachment surgery, consisting of repair of complete retinal detachment by vitrectomy with removal of epiretinal membranes? The dictation does not include a diagnosis of glaucoma.

A. Peripheral iridectomies usually are performed prophylactically for complicated and/or difficult vitreoretinal cases in aphakia. If silicone oil is used, the peripheral iridectomy may be performed to avoid later pupillary block glaucoma.

Another use might be during retinal detachment repair in an eye where an anterior chamber intraocular lens had been inserted previously.

CPT codes copyright 2006 American Medical Association. RP

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