Extended ophthalmoscopy (EO) is a useful tool for retina specialists dealing with serious posterior segment disease. Our analysis of Medicare utilization rates for claims paid in 2015 shows that EO was associated with 16% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 16 times. Only scanning computerized ophthalmic diagnostic imaging of the retina (CPT 92134) occurs more often — 19% of all eye exams. Consequently, it’s important to understand what is needed to warrant reimbursement and ensure that you will prevail during postpayment scrutiny.
There are considerable regional differences in the frequency of this service, but in every part of the country, EO is flagged as an overutilized service and is subject to frequent Medicare audits. In a retinal practice, it is likely that EO will occur more often than the norm, attracting added scrutiny. By paying attention to the quality of the retinal drawings as well as the severity and progression of the disease, you can win in a challenge to your utilization pattern for EO.
LET’S START WITH THE BASICS: WHAT IS EO?
Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy of an eye exam. Pupil dilation is implicit. Binocular indirect ophthalmoscopy (BIO) is preferred; it may include scleral depression. Extended ophthalmoscopy 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).
92225 pertains to the initial evaluation of a disease, while 92226 involves 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 an initial EO has been performed on an eye, it is possible to do another initial test for a new condition.
It is critical to note that the basis for reimbursement is serious pathology, along with detailed retinal drawing of the pathology. Reimbursement for routine BIO is part of an eye examination and EO should not be billed. As noted in CPT, “Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a non-itemized service and is not reported separately.”
WHAT DIAGNOSES SUPPORT THE USE OF 92225 AND 92226?
Extended ophthalmoscopy is indicated for serious retinal pathology. Most Medicare administrative contractors (MACs) have published local coverage determination (LCD) policies. MACs, and other payers, do not all agree on a single list of covered diagnoses. Many of the commonly included codes are noted in Table 1.
|Z79.899||High-risk medication (eg, Plaquenil)|
|C69.3-||Malignant neoplasm choroid|
|C69.2-||Malignant neoplasm retina|
|H33.3-||Retinal defect without retinal detachment|
|H33.-||Retinal detachment and breaks|
|Note: This list is neither comprehensive nor universally accepted. Check your local coverage policies.|
WHAT DOCUMENTATION IS REQUIRED IN THE CHART TO SUPPORT EO?
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. A retinal drawing is a necessary component of the documentation. Although policies differ, some charting requirements are common, including the following:
- The documentation must be legible.
- Retinal drawings must be maintained in the patient’s record.
- Drawings should include sufficient detail, standard colors, and appropriate labels.
The utility of the retinal drawing is apparent when the patient returns for re-evaluation of the same condition. The ophthalmologist can compare what is observed today with the prior retinal drawing. Where there is clinically significant change, another retinal drawing should be made to serve as a new benchmark for future comparison. If no apparent change is noted, then another duplicative retinal drawing is not needed or justified. The new drawing that reflects the clinically significant change is the support for a subsequent EO (92226).
In addition, when EO is billed for a diagnosis of glaucoma, documentation in the patient’s medical record must include all of the following:
- A detailed drawing of the optic nerve;
- Documentation of cupping, disc rim, pallor, and slope; and
- Documentation of any surrounding pathology around the optic nerve.
Most LCDs simply state that the drawing must be “detailed,” without specifying a size. Some LCDs do include size requirements, usually 2.5 inches to 3 inches. We believe it is difficult to provide sufficient detail in a smaller drawing.
WHAT OTHER ATTRIBUTES MAKE A HIGH-QUALITY EO RETINAL DRAWING?
The retinal drawing should be anatomically specific to the patient, with an interpretation and report. The drawing should have the following characteristics:
- Scaled to depict relative size;
- Colored using classical representations (red for hemorrhage, blue for detachment, and so on);1
- Detailed including macula, optic nerve, vessels, and periphery;
- Labeled findings;
- Individual for each eye;
- Separate from the eye exam; and
- Without any preprinted anatomical elements (eg, optic nerve, vascular arcades).
WHAT DOES MEDICARE ALLOW FOR 92225 AND 92226?
CMS defines EO as “unilateral,” so reimbursement is per eye. The 2017 national Medicare Physician Fee Schedule allowable is $27.28 for 92225 and $25.12 for 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 fee schedule.
WHAT OTHER ISSUES IMPACT EO?
At present, EO is bundled with most retinal surgery codes under the National Correct Coding Initiative (NCCI); in addition, the 2 codes are mutually exclusive. Some LCDs also state that EO is not payable on the same day as OCT (92133, 92134), and a few payers also bundle EO with fundus photography. We infer that EO and imaging studies performed concurrently on the same eye that contain the same information are redundant and that only the more intensive service should be billed. RP
- Aetna. Extended ophthalmoscopy. Policy number 0767. http://www.aetna.com/cpb/medical data/700_799/0767.html . Accessed June 10, 2017.