Coding Q&A

Rules for scribing and extended ophthalmoscopy


Rules for Scribing and Extended Ophthalmoscopy

Information Provided By Riva Lee Asbell

Q. First question: can a scribe legally draw an extended ophthalmoscopy as long as I tell him/her exactly how to draw what and where?

A. A scribe cannot do any physician work—the drawing is part of the physician work as the code is described in CPT. The answer is no.

Q. I have a follow-up. What about the interpretation? Can I have the scribe write that if I “dictate” it?

A. Again, the fulfillment of the “Interpretation and Report” requirement for ophthalmic diagnostic testing is considered physician work. (See for the article “The Three Cs: Interpretation and Report Requirements for Ophthalmic Diagnostic Testing”). Moreover, there are strict regulations for scribing.

Q. Can a scribe use a stamp stating, “Acting as a scribe for Dr. X,” then sign their name on the bottom of whatever it is they are scribing for the doctor?

A. No, see complete requirements below in the commentary.

Commentary on the Use of Scribes from Medicare:

“Physicians may on occasion utilize the services of scribes to assist with documentation during a clinical encounter between the physician and patient. The scribe is present during the encounter and records in real time the actions and words of the physician as they occur. Scribes may not interject their own observations or impressions into the medical record.

“The physician is ultimately responsible for all documentation and must verify that the scribe's note accurately reflects the service provided.”

The scribe's note should also include:

► The name of the scribe and a legible signature.
► The name of the physician providing the service.
► The date the service was provided.
► The name of the patient for whom the service was provided.

The physician's note is required to indicate:

► Affirmation of that physician's presence during the time encounter was recorded.
► Verification that he/she reviewed the information.
► Verification of the accuracy of the information.
► Any additional information needed.

In a teaching facility setting, attending physicians may employ scribes, but residents or fellows may not, since the creation of the medical record is inherent to the training program and to the medical care delivered by these residents.

Q. Can extended ophthalmoscopy (92225/92226) be charged along with an eye code?

A. Extended ophthalmoscopy can be billed with either the E/M codes or the eye codes. A word of caution—do not use higher level E/M codes without documenting the routine ophthalmoscopy as part of the examination before going on to extended ophthalmoscopy. Don't skip from dilation to extended ophthalmoscopy and double dip.

Q. I understand that Medicare no longer requires color drawings for extended ophthalmoscopy (just detailed and labeled). Do other insurers require them?

A. There is no national policy on extended ophthalmoscopy, only Local Coverage Determinations by your Medicare Contractor/Carrier or any other insurance carrier. You must abide by their requirements. Some require color and others suggest using color in the drawings. Even if there is a retired policy, adhere to it.

Q. What size drawing is needed for extended and subsequent ophthalmoscopy? Does it have to be on a separate piece of paper and not on our exam sheet? On our exam sheet, the retina circles are 1.75-inch diameter.

A. I recommend a 2.75-inch to 3-inch diameter. It does not have to be on a separate piece of paper, but it has to be anatomically specific to that patient and labeled clearly. In addition, there must be a separate Interpretation and Report. RP

CPT codes ©2011 American Medical Association.

Riva Lee Asbell can be contacted at, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.