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 Codes | Description |
---|---|
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 |