Extended Ophthalmoscopy and Audit Preparedness for Retinal Physicians

Be aware of vulnerabilities.


Each year, retina practices face billing challenges, and 2020 is no different. Retina specialists may become overwhelmed by the enormous changes to extended ophthalmoscopy codes and an uptick in audit requests. Here, we break down what retina specialists need to know and what steps they should take to retain income to which they are entitled.

Extended Ophthalmoscopy CPT Codes Have Changed

Extended ophthalmoscopy (EO) codes 92225 and 92226 were deleted on December 31, 2019, by all payers. During the Relative Value Scale Update Committee (RUC) review, it was determined that both codes involved the same physician work and differed only in initial and subsequent language of the codes. Therefore, 2 new codes were developed to identify the peripheral and posterior examination differences:

92201: Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.

92202: Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral and bilateral.

Documentation Requirements

What documentation do payers require?


  • As published in the CPT description: Scleral depression, unless, of course, contraindicated.
  • Detailed drawing of peripheral retinal disease that is labeled.


  • Detailed drawing of optic nerve or macula that is labeled.

Frequency Edits

Every test in CPT has frequency edits that are typically not published. Medicare Part B also restricts the frequency of any test, including EO, to patient and not to each physician. Note that payers may exclude coverage of EO when it is performed during a global period.


Historically, EO codes had unilateral payment or payment per eye when there was pathology that could not be documented any other way except by a drawing. Both 92201 and 92202 are defined as unilateral or bilateral, which means payment is the same whether one or both eyes are examined. Therefore, modifiers -RT, -LT or -50 should be used. Reimbursement for CPT code 92201 on average decreased the value approximately 9% when compared to CPT code 92225, whereas 92202 indicates a 32% reduction.

National Medicare average allowable is the following, but check your payer’s fee schedule:

CPT Code 92201: $25.85

CPT code 92201: $16.42

Bundling Edits

The National Correct Coding Initiative (NCCI) edits indicate whether 2 or more services can be paid when performed on the same day. The new EO codes were impacted with bundling edits.

Effective January 1, 2020, NCCI V26.0 bundles both 92201 and 92202 with all retinal lasers and surgeries when performed the same day. The bundling indicator is a 1, which means it is appropriate to unbundle the 2 codes when the laser or surgery is in 1 eye and performance of EO is medically necessary in the other eye. Note that even though EO is now inherently bilateral, if the test is medically necessary and documentation supports the drawing, you can attempt to unbundle with modifier -59 if surgery is in the opposite eye from the test. The payer may or may not allow.

Additionally, 92201 and 92202 have a mutually exclusive bundle, as do 92201 and 92202 with CPT code 92250 fundus photography.

Preparation for Retina-Focused Audits

While the Centers for Medicare & Medicaid Services (CMS) have paused chart reviews during the COVID-19 public health emergency, practices need to understand that audits will not be going away indefinitely. The American Academy of Ophthalmology fields thousands of calls and emails annually of audit-related issues, with 70% attributed to retina practices. This is due to the high volume of services performed. Although many types of audits take place simultaneously, being prepared with accurate documentation and appropriate coding is the best defense. This includes knowing who may come knocking.

Record Requests

CMS has multiple bodies reviewing records with some overlap on areas of interest. Although some are assigned to contractors, others begin with each Medicare Administrative Contractor (MAC). The 3 main audits with a focus on retina are the Office of Inspector General (OIG), Target Probe and Educate (TPE) audits, and Recovery Audit Contractors (RA or RAC).

The OIG conducts criminal, civil, and administrative reviews with focus on fraud, waste, and abuse within Medicare, Medicaid, and other US Department of Health & Human Services programs. Claims submitted to CMS were added to their 2019 work plan. The 2 areas include intravitreal injection of Eylea or Lucentis and evaluation and management (E/M) services submitted the same day as injections. In 2014, the OIG reported that $22.3 million in “potentially inappropriate” payments were made from Medicare contractors for 2012 services.

Target Probe and Educate audits are prepayment and postpayment reviews in specific areas determined by each MAC. Each MAC’s selection of codes is based on claims error rates and unusual billing patterns of physicians and suppliers. These services typically have high national average error rates. TPE audits can have up to 3 rounds and require a response within 45 days or failure is automatic. Records requests range between 20 to 40 records and may require a one-on-one review with the auditor. If a physician fails all 3 rounds, the MAC can provide their findings to CMS, where further action may take place, including 100% prepayment review, extrapolation, or referral to another investigative body.

Intravitreal injections continue to be the greatest focus for retina specialists’ audits. MACs with reviews include Cigna Government Services, Noridian, and Novitas. A list of all MACs can be found at . If prepayment review should take place, this can negatively impact a retina practice’s financial stability, so consistent review of claims and correction of found errors should be a priority. Other areas of focus impacting retina include new and established office-based E/M codes, initial inpatient and subsequent hospital E/M codes, emergency department codes, and critical care E/M codes.

Recovery audits (RA) are facilitated by 3 contractors assigned by CMS. To determine the contractor in your state, check with your MAC or go to . Audits aim to identify improperly made payments by MACs and eliminate future errors of incorrectly paid claims. They conduct review in 2 ways:

  1. Automated review of claims data. This data-driven request is based on incorrectly billed and paid claims. No chart notes are requested for review. The practice receives a request for refund, and action must take place within the provided time frame. Payment can be withheld from either you or other partners of the practice if the refund is not paid in the time allotted. Automated reviews, when appropriate, can be appealed by the physician.
  2. Complex review of charts. These reviews include a request for supporting chart documentation for services paid. The physician receives an additional documentation request (ADR) and must submit all requested content within 45 days. Services may then be denied and a recoupment request activated. Complex reviews, when appropriate, can be appealed by the physician.

One area of focus in recovery audits includes the appropriate billing of intravitreal medication units. An example is incorrectly billing Eylea with 1 unit instead of 2. The RA would identify the error as an underpayment and pay for the additional unit. In other cases, they may identify an overpayment leading to a recoupment. Other targeted areas are billing exams the same day as minor surgeries, or within the global period of major surgeries.

Document to Meet Guidelines

Although you need to confirm documentation requirements with your payer, because many payers have unique policies for services performed, there are some standard documentation requirements to be aware of and meet to avoid potential recoupments. See the example checklist below.

Intravitreal injections checklist:

  • Diagnosis supporting medical necessity and appropriate indication for use
  • Any relevant diagnostic testing services, with interpretation and report
  • Risks, benefits, and alternative discussed
  • Physician’s order includes the following:
    • Date of service
    • Medication name and dosage
    • Diagnosis
    • Physician signature
  • Interval of administration is appropriate, such as 28-day rule
  • Procedure record includes the following:
    • Diagnosis
    • Route of administration (intravitreal injection) and medication name
    • Site of injection - eye(s) treated
    • Dosage in mg and volume in mL (ie, Avastin 1.25 mg/0.05 mL) and lot number
    • Single-use medications record wastage greater than 1 unit (ie, Triesence)
    • For wastage of less than 1 unit, “any residual medication less than one unit has been discarded” is documented
    • Completed consent for injection, medication, and eye(s) on file
    • For initial treatment using a medication with off-label use, an informed consent with that notification is completed (ie, Avastin)
    • Advance Beneficiary Notice (ABN) for Medicare Part B beneficiaries or waiver of liability (all other patients) is completed if applicable
  • Chart record is legible and has correct patient name and date of birth
  • Physician signature is legible
    • Paper chart records have a signature log
    • EHR, the electronic physician signature is secure
  • Abbreviations are consistent with approved list and readily available for audits
  • CPT 67028, eye modifier appended (-RT or -LT)
    • Bilateral injections billed with a -50 modifier per payer guidelines. (Medicare Part B claims billed with 67028-50 on one line, fees doubled, and 1 unit.)
  • Healthcare Common Procedure Coding System (HCPCS) J code for medication
  • Appropriate units administered (ie, Eylea 2 units)
  • HCPCS J code on a second line for wasted medication, if appropriate
    • -JW modifier appended
  • Medically necessary ICD-10 code appropriately linked to 67028 and J code(s)
  • On the insurance claim in box 24a or Electronic Data Interchange loop 2410
    • 11-digit National Drug Code in 5-4-2 format
      • Description of dosage per insurance guidelines

Action Plan for Practice

Monitoring the types of audits being conducted is the first step in preparation. Followed by continued comprehensive internal reviews, monitoring will ensure you are ready for the inevitable audit.

Know your resources. The American Academy of Ophthalmology provides the current audits and targets for your region, as well as the local coverage determination polices and articles by your MACs. These policies include payable CPT and ICD-10 codes, plus documentation requirements and even, when available, frequency limitations. Each practice should create an internal checklist outlining payer documentation requirements and conduct a targeted internal chart audit. When errors are found, take appropriate corrective action. Education for all physicians and staff on the results of your review is a good way to ensure they are not repeated.