92225_R05

Extended ophthalmoscopy is an assessment of the posterior segment of the eye (vitreous, retina, optic disc, choroids, etc.) with the pupil dilated using indirect ophthalmoscopy or slit lamp biomicroscopy.  These techniques employ an additional diagnostic tool (eg, 3-mirror lens, 20-diopter lens, 90-diopter lens, scleral depression) and include a detailed drawing of the retina.  Extended ophthalmoscopy provides a high intensity illumination, stereoscopic, wide field of view of the ocular fundus for detection and/or evaluation of vitreoretinal pathology.

Extended ophthalmoscopy codes are reserved for the meticulous evaluation of the eye in detailed documentation of a severe ophthalmologic problem needing continued follow-up, which cannot be sufficiently evaluated by photography.

Medicare will consider ophthalmoscopy (CPT Codes 92225, 92226) to be medically reasonable and necessary if any one of the following circumstances is present:

• The patient has a malignant neoplasm of the retina or choroid.  This may appear as a single, round or oval, slightly elevated, gray or nonpigmented lesion.
• The patient has a retained (old) intraocular foreign body, either magnetic or nonmagnetic.  Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing.
• The patient has retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration
• The patient has retinal detachment with or without retinal defect.  The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse.  This may be described by the patient as “a curtain came down over my eyes.”
• The patient has retinal defects without retinal detachment
• The patient has diabetic retinopathy ( e.g., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation
• The patient has experienced sudden visual loss or transient visual loss.  This may be described as trouble seeing or vision going in and out. 
• The patient has chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment
• The patient has Vogt-Koyanagi syndrome.  This disease is characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment.  The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea.
• The patient has sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye
• The patient has disorders of the vitreous body (e.g., vitreous hemorrhage or posterior vitreous detachment). Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders.
• The patient has posterior scleritis.  Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field.
• The patient has degenerative disorders of the globe
• The patient has retinoschisis and retinal cysts. Patients may complain of light flashes and floaters
• The patient has signs and symptoms of endophthalmitis which may include severe pain, redness, photophobia, and profound loss of vision
• The patient has glaucoma or is a glaucoma suspect.  This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve. The patient’s medical record must meet the documentation requirements set forth in this policy.

In all instances extended ophthalmoscopy must be medically necessary.  It must add information not available from the standard evaluation services and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means.