CPT Code: 92225  Region: 37

States covered:  General guidelines if your state does not have a local coverage determination

Title:  Extended Ophthalmoscopy for the Initial Visit

Category
Special Ophthalmological Services

Description
Extended Ophthalmoscopy with retinal drawings (eg, for retinal detachment, melanoma) with interpretation and report for the initial visit"

This Medicare carrier does not have a local coverage determination (LCD) for this particular diagnostic test.  It is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.  



Extended ophthalmoscopy includes a drawing of the retina observed through a dilated pupil (unless dilation is clinically contraindicated), a written interpretative report, and a documented plan of treatment.

1.   Identification and/or follow-up for glaucoma suspect with evidence of any of the following:

  • Increase in intraocular pressure
  • Asymmetric intraocular pressure measurements greater than 2-3 mmHg between the two eyes
  • Optic nerves suspicious for glaucoma
  • Asymmetrical cupping
  • Disc hemorrhage
  • An absent or thinned temporal neuroretinal rim

2.  Identification and/or follow-up for glaucoma

3.  Identification and/or follow-up for optic nerve disease 

  • Evidence of a pale or swollen optic nerve documented by a recent exam
  • Assessment of drusen of the optic disc

4.  Identification and/or follow-up for retinal disease 

  • Macular degeneration
  • Retinal edema
  • Retinoschisis and retinal cysts
  • Neoplasm of the retina
  • Retinal defect without retinal detachment
  • Retinal detachment with or without retinal defect
  • Retinal hemorrhages, edema, ischemia, exudates, deposits, hereditary retinal dystrophies or peripheral retinal degeneration

5.  Identification and follow-up for disorders of the choroid 

  • Neoplasms of the choroid
  • Choroidal nevus being evaluated for malignant transformation
  • Chorioretinitis, chorioretinal scars, choroidal degeneration, dystrophies, hemorrhage, rupture and detachments

6.  Identification and/or follow-up for disorders of the vitreous 

  • Vitreous hemorrhage
  • Posterior vitreous detachment
  • Patients with signs/symptoms of flashes and floaters

7.  Identification and/or follow-up for disorders of the globe 

  • Endophthalmitis
  • Degenerative disorders of the globe
  • Hight axial length myopia

8.  Identification and/or follow-up for posterior scleritis 

  • Assessment of patients with the signs and symptoms of severe pain and inflammation, proptosis, limited ocular movement and partial loss of visual field.

9.  Identification and/or follow-up for visual disturbances 

  • Sudden or transient vision loss
  • Visual field defects
  • Metamorphopsia

10.  Identification and/or follow-up for patients on long-term use of high-risk medication that can produce retinopathy or optic neuropathy

11.  Identification and/or follow-up for significant eye injury 

  • Penetrating would to the orbit resulting in a retention of a foreign body
  • Blunt injury to the eye

12.  Identification and/or follow-up for systemic disease which may be associated with retinal disease 

  • Diabetes
  • HIV
  • Vogt-Kayanagi Syndrome
  • Rheumatoid arthiritis
  • Marfan Syndrome

ICD-10 Diagnosis Codes

ICD-10 CodesDescription
B39.9 Histoplasmosis, unspecified
B58.01 Toxoplasma chorioretinitis
C69.20 - C69.22 Malignant neoplasm of unspecified retina - Malignant neoplasm of left retina
C69.30 - C69.32 Malignant neoplasm of unspecified choroid - Malignant neoplasm of left choroid
D18.09 Hemangioma of other sites
D31.20 - D31.22 Benign neoplasm of unspecified retina - Benign neoplasm of left retina
D31.30 - D31.32 Benign neoplasm of unspecified choroid - Benign neoplasm of left choroid
D33.3 Benign neoplasm of cranial nerves
E08.311 - E08.3599 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye
E09.311 - E09.3599 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E10.311 - E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.3211 - E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3291 - E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3311 - E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3411 - E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3511 - E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E11.311 - E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211 - E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311 - E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411 - E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511 - E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E13.311 - E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema - Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.3211 - E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3311 - E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3411 - E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3511 - E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
G45.3 Amaurosis fugax
H05.50 - H05.53 Retained (old) foreign body following penetrating wound of unspecified orbit - Retained (old) foreign body following penetrating wound of bilateral orbits
H15.031 - H15.039 Posterior scleritis, right eye - Posterior scleritis, unspecified eye
H16.241 - H16.249 Ophthalmia nodosa, right eye - Ophthalmia nodosa, unspecified eye
H20.00 - H20.059 Unspecified acute and subacute iridocyclitis - Hypopyon, unspecified eye
H20.821 - H20.829 Vogt-Koyanagi syndrome, right eye - Vogt-Koyanagi syndrome, unspecified eye
H21.331 - H21.339 Parasitic cyst of iris, ciliary body or anterior chamber, right eye - Parasitic cyst of iris, ciliary body or anterior chamber, unspecified eye
H27.10 Unspecified dislocation of lens
H27.111 - H27.119 Subluxation of lens, right eye - Subluxation of lens, unspecified eye
H27.131 - H27.139 Posterior dislocation of lens, right eye - Posterior dislocation of lens, unspecified eye
H30.001 - H30.049 Unspecified focal chorioretinal inflammation, right eye - Focal chorioretinal inflammation, macular or paramacular, unspecified eye
H30.101 - H30.149 Unspecified disseminated chorioretinal inflammation, right eye - Acute posterior multifocal placoid pigment epitheliopathy, unspecified eye
H30.20 - H30.23 Posterior cyclitis, unspecified eye - Posterior cyclitis, bilateral
H30.811 - H30.899 Harada's disease, right eye - Other chorioretinal inflammations, unspecified eye
H30.90 - H30.93 Unspecified chorioretinal inflammation, unspecified eye - Unspecified chorioretinal inflammation, bilateral
H31.001 - H31.099 Unspecified chorioretinal scars, right eye - Other chorioretinal scars, unspecified eye
H31.101 - H31.129 Choroidal degeneration, unspecified, right eye - Diffuse secondary atrophy of choroid, unspecified eye
H31.20 - H31.29 Hereditary choroidal dystrophy, unspecified - Other hereditary choroidal dystrophy
H31.301 - H31.329 Unspecified choroidal hemorrhage, right eye - Choroidal rupture, unspecified eye
H31.401 - H31.429 Unspecified choroidal detachment, right eye - Serous choroidal detachment, unspecified eye
H32 Chorioretinal disorders in diseases classified elsewhere
H33.001 - H33.059 Unspecified retinal detachment with retinal break, right eye - Total retinal detachment, unspecified eye
H33.101 - H33.119 Unspecified retinoschisis, right eye - Cyst of ora serrata, unspecified eye
H33.121 - H33.129 Parasitic cyst of retina, right eye - Parasitic cyst of retina, unspecified eye
H33.191 - H33.199 Other retinoschisis and retinal cysts, right eye - Other retinoschisis and retinal cysts, unspecified eye
H33.20 - H33.23 Serous retinal detachment, unspecified eye - Serous retinal detachment, bilateral
H33.301 - H33.339 Unspecified retinal break, right eye - Multiple defects of retina without detachment, unspecified eye
H33.40 - H33.43 Traction detachment of retina, unspecified eye - Traction detachment of retina, bilateral
H33.8 Other retinal detachments
H34.00 - H34.9 Transient retinal artery occlusion, unspecified eye - Unspecified retinal vascular occlusion
H35.00 - H35.09 Unspecified background retinopathy - Other intraretinal microvascular abnormalities
H35.111 - H35.169 Retinopathy of prematurity, stage 0, right eye - Retinopathy of prematurity, stage 5, unspecified eye
H35.171 - H35.179 Retrolental fibroplasia, right eye - Retrolental fibroplasia, unspecified eye
H35.20 - H35.23 Other non-diabetic proliferative retinopathy, unspecified eye - Other non-diabetic proliferative retinopathy, bilateral
H35.30 - H35.33 Unspecified macular degeneration - Angioid streaks of macula
H35.341 - H35.349 Macular cyst, hole, or pseudohole, right eye - Macular cyst, hole, or pseudohole, unspecified eye
H35.351 - H35.359 Cystoid macular degeneration, right eye - Cystoid macular degeneration, unspecified eye
H35.361 - H35.369 Drusen (degenerative) of macula, right eye - Drusen (degenerative) of macula, unspecified eye
H35.371 - H35.379 Puckering of macula, right eye - Puckering of macula, unspecified eye
H35.381 - H35.389 Toxic maculopathy, right eye - Toxic maculopathy, unspecified eye
H35.40 - H35.469 Unspecified peripheral retinal degeneration - Secondary vitreoretinal degeneration, unspecified eye
H35.50 - H35.54 Unspecified hereditary retinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium
H35.60 - H35.63 Retinal hemorrhage, unspecified eye - Retinal hemorrhage, bilateral
H35.70 - H35.739 Unspecified separation of retinal layers - Hemorrhagic detachment of retinal pigment epithelium, unspecified eye
H35.81 - H35.89 Retinal edema - Other specified retinal disorders
H36 Retinal disorders in diseases classified elsewhere
H40.001 - H40.069 Preglaucoma, unspecified, right eye - Primary angle closure without glaucoma damage, unspecified eye
H40.10X0 - H40.1394 Unspecified open-angle glaucoma, stage unspecified - Pigmentary glaucoma, unspecified eye, indeterminate stage
H40.1410 - H40.1494 Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified - Capsular glaucoma with pseudoexfoliation of lens, unspecified eye, indeterminate stage
H40.151 - H40.159 Residual stage of open-angle glaucoma, right eye - Residual stage of open-angle glaucoma, unspecified eye
H40.20X0 - H40.249 Unspecified primary angle-closure glaucoma, stage unspecified - Residual stage of angle-closure glaucoma, unspecified eye
H40.30X0 - H40.53X4 Glaucoma secondary to eye trauma, unspecified eye, stage unspecified - Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.60X0 - H40.63X4 Glaucoma secondary to drugs, unspecified eye, stage unspecified - Glaucoma secondary to drugs, bilateral, indeterminate stage
H40.811 - H40.839 Glaucoma with increased episcleral venous pressure, right eye - Aqueous misdirection, unspecified eye
H40.89 Other specified glaucoma
H40.9 Unspecified glaucoma
H42 Glaucoma in diseases classified elsewhere
H43.00 - H43.9 Vitreous prolapse, unspecified eye - Unspecified disorder of vitreous body
H44.001 - H44.029 Unspecified purulent endophthalmitis, right eye - Vitreous abscess (chronic), unspecified eye
H44.111 - H44.19 Panuveitis, right eye - Other endophthalmitis
H44.20 - H44.23 Degenerative myopia, unspecified eye - Degenerative myopia, bilateral
H44.2A1 - H44.2E9 Degenerative myopia with choroidal neovascularization, right eye - Degenerative myopia with other maculopathy, unspecified eye
H44.311 - H44.329 Chalcosis, right eye - Siderosis of eye, unspecified eye
H44.601 - H44.609 Unspecified retained (old) intraocular foreign body, magnetic, right eye - Unspecified retained (old) intraocular foreign body, magnetic, unspecified eye
H44.621 - H44.629 Retained (old) magnetic foreign body in iris or ciliary body, right eye - Retained (old) magnetic foreign body in iris or ciliary body, unspecified eye
H44.641 - H44.649 Retained (old) magnetic foreign body in posterior wall of globe, right eye - Retained (old) magnetic foreign body in posterior wall of globe, unspecified eye
H44.651 - H44.659 Retained (old) magnetic foreign body in vitreous body, right eye - Retained (old) magnetic foreign body in vitreous body, unspecified eye
H44.701 - H44.709 Unspecified retained (old) intraocular foreign body, nonmagnetic, right eye - Unspecified retained (old) intraocular foreign body, nonmagnetic, unspecified eye
H44.741 - H44.749 Retained (nonmagnetic) (old) foreign body in posterior wall of globe, right eye - Retained (nonmagnetic) (old) foreign body in posterior wall of globe, unspecified eye
H44.751 - H44.759 Retained (nonmagnetic) (old) foreign body in vitreous body, right eye - Retained (nonmagnetic) (old) foreign body in vitreous body, unspecified eye
H46.2 Nutritional optic neuropathy
H46.3 Toxic optic neuropathy
H46.9 Unspecified optic neuritis
H47.011 - H47.099 Ischemic optic neuropathy, right eye - Other disorders of optic nerve, not elsewhere classified, unspecified eye
H47.10 Unspecified papilledema
H47.20 - H47.299 Unspecified optic atrophy - Other optic atrophy, unspecified eye
H47.311 - H47.399 Coloboma of optic disc, right eye - Other disorders of optic disc, unspecified eye
H53.121 - H53.129 Transient visual loss, right eye - Transient visual loss, unspecified eye
H53.131 - H53.139 Sudden visual loss, right eye - Sudden visual loss, unspecified eye
H53.19 Other subjective visual disturbances
H59.021 - H59.029 Cataract (lens) fragments in eye following cataract surgery, right eye - Cataract (lens) fragments in eye following cataract surgery, unspecified eye
H59.031 - H59.039 Cystoid macular edema following cataract surgery, right eye - Cystoid macular edema following cataract surgery, unspecified eye
Q14.0 - Q14.9 Congenital malformation of vitreous humor - Congenital malformation of posterior segment of eye, unspecified
Q15.0 Congenital glaucoma
Q85.1 Tuberous sclerosis
Q85.8 Other phakomatoses, not elsewhere classified
Q85.9 Phakomatosis, unspecified
Q87.42 Marfan's syndrome with ocular manifestations
S05.10XA - S05.12XS Contusion of eyeball and orbital tissues, unspecified eye, initial encounter - Contusion of eyeball and orbital tissues, left eye, sequela
S05.20XA - S05.22XS Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial encounter - Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela
S05.30XA - S05.32XS Ocular laceration without prolapse or loss of intraocular tissue, unspecified eye, initial encounter - Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela
S05.50XA - S05.52XS Penetrating wound with foreign body of unspecified eyeball, initial encounter - Penetrating wound with foreign body of left eyeball, sequela
S05.60XA - S05.62XS Penetrating wound without foreign body of unspecified eyeball, initial encounter - Penetrating wound without foreign body of left eyeball, sequela
S05.70XA - S05.72XS Avulsion of unspecified eye, initial encounter - Avulsion of left eye, sequela


1.  The medical record should clearly indicate the condition being evaluated and the primary diagnosis should support the medical necessity of the procedure.  In addition, indications for extended ophthalmoscopy should be entered into the medical record on a case-by-case and eye-by-eye basis.

2.  Extended ophthalmoscopy should meet the following documentation requirements:

  • A separate detailed sketch of the retina accurately representing normal, abnormal and common finding such as lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, retinal detachments, holes, tears or tumors.
  • All items noted on the sketch should be identified and labeled.
  • Optic nerve abnormalities should be drawn separately.
  • Drawings using 4-6 standard colors are preferred;howver, non-colored drawings are acceptable if they are clearly labeled.

3.  Extended ophthalmoscopy drawings should be maintained in the patient’s medical record with an interpretation and report and the following noted: 

  • Method of examination (scleral depression, 3-mirrored lens, 20 diopter lens, 90 diopter lens)
  • The drug used for pupil dilation
  • All posterior pole findings and a treatment plan

4.  Patients with a glaucoma diagnosis should meet the following documentation requirements for extended ophthalmoscopy: 

  • A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment.
  • Documentation of cupping, disc rim, pallor, sloping or any pathology surrounding the optic nerve.

5.  Documentation must be legible and made available to Medicare upon request.

1.  Report extended ophthalmoscopy with CPT code 92225 for the initial visit.

2.  Extended ophthalmoscopy is a professional service.  Therefore, the use of modifiers for professional (-26) and technical components (TC) is not appropriate for these codes.

3.  An eye examination may be reported on the same day as extended ophthalmoscopy if it is medically necessary. 

CPT code 92225 is payable with CPT codes 92002, 92004, 92012 and 92014

4.  Indirect ophthalmoscopy done without a drawing is part of the general ophthalmologic examination and should not be billed separately as extended ophthalmoscopy.

5.  Routine ophthalmoscopy and biomicroscopy are part of the general ophthalmologic examination and should not be billed separately as extended ophthalmoscopy.

Medicare has determined that extended ophthalmoscopy should add clinical information that is not available from the general ophthalmologic examination and the procedure should provide information that will affect the treatment plan.

If other diagnostic tests, such as fundus photography, fluorescien angiography or ophthalmic ultrasound have been performed, extended ophthalmoscopy should not be utilized unless it can provide non-duplicated additional information.

Extended ophthalmoscopy should not be routinely used on both eyes of every patient on all visits.

Medicare has no specific utilization guidelines for extended ophthalmoscopy.  In the absence of specific utilization guidelines, optometrists should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of optometric practice.

RETINAL DRAWING COLOR SCHEME

Red Retinal arteries, retinal hemorrhage, attached retina
Blue Retinal veins, detached retina
Yellow Chorioretinal exudates, intraretinal exudates, intraretinal edema
Green Opacities in media, vitreous hemorrhage
Purple Flat neovascularization
Orange Elevated neovascularization
Brown Retinal pigment epithelium, choroidal pigmentation seen through attached retina, vascular occlusion
Blue outlined filled with red Full thickness sensory retinal break
Blue outlined cross-hatched with red Partial thickness sensory retinal break
Black outline filled with black lattice pattern Lattice degeneration of attached retina
Blue outline filled with blue lattice pattern Lattice degeneration of detached retina
Black outline cross-hatched with red Paving-stone degeneration of attached retina
Brown outline cross-hatched with red Paving-stone degeneration seen through detached retina
Blue lines (short) Retinal tufts and meriodinal folds
Black scalloped line overlaying ora serrata circle on fundus chart Ora serrata with adjacent detached retina