92226_R02

The patient’s medical record must contain documentation that fully supports the medical necessity for extended ophthalmoscopy for each eye, as it is covered by Medicare.  This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Retinal drawings must be maintained in the patient’s record.

• There must be a separate detailed sketch, minimal size of 3-4 inches
• All items noted must be identified and labeled
• Drawings in four (4) – six (6) standard colors are preferred.  However, non-colored drawings are also acceptable, if clearly labeled.
• Optic nerve abnormalities should be separately drawn
• An extensive scaled drawing must accurately represent normal, abnormal and common findings such as:  lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears or tumors

Documentation in the patient’s medical record for a diagnosis of glaucoma (ICD-10-CM codes H40.001-H40.152 Glaucoma) must include all of the following:

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

Documentation specific to the method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.

The medical record should document whether the pupil was dilated, and which drug was used.

All findings and a plan of action should be documented in notes.

Although routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, these should still be documented in the patient’s medical record.

Documentation supporting the medical necessity should be legible, maintained in the patient’s record, and must be available to the carrier upon request.

CPT code 92226 is a unilateral code and must be submitted with a site modifier (LT, RT or -50).  A claim without the appropriate modifier (RT, LT or -50) will be returned as incomplete.  Each service must be billed with an NOS of 001, even if performed bilaterally and billed with a modifier -50.

An initial ophthalmoscopy (CPT code 92225) and a subsequent ophthalmoscopy (CPT code 92226) will not be reimbursed on the same day for the same eye by the same provider.  If an initial ophthalmoscopy (CPT code 92225) and a subsequent ophthalmoscopy (CPT code 92226) are performed on different eyes modifier RT and LT should be reported to indicate that the services were performed on different eyes.

Extended ophthalmoscopy is classified as a professional service.  The use of professional or technical component modifiers (-26, TC), with these codes, is not appropriate.

Code 92226 is payable only with exam codes 92012 and 92014.

If extended ophthalmoscopy is performed during a global surgery period, unrelated to the condition for which the surgery was performed (same provider), then the extended ophthalmoscopy should be coded with a modifier -79 attached (in addition to the appropriate site modifier).

Indirect ophthalmoscopy done without a drawing may not be billed separately and is part of a general ophthalmologic exam (92002-92014).

Patients actively being treated with intravitreal injections of medication for exudative AMD (ICD-10-CM code H35.32) may require up to 12 extended ophthalmoscopies per eye, per year.

Conditions coded with other ICD-10-CM codes in the ranges A18.53; A18.54; E08.311-E08.359 Diabetes mellitus due to underlying condition with ophthalmic complications E09.311-E09.359 Drug or chemical induced diabetes mellitus with ophthalmic complications;E10.311-E10.359 Type 1 diabetes mellitus with ophthalmic complications; E11.311-E11.359 Type 2 diabetes mellitus with ophthalmic complications; E13.311-E13.359 Other specified diabetes mellitus with ophthalmic complications; H16.241-H16.249 Ophthalmia nodosa; H20.00-H21.1X1; G45.3 Diseases of the eye and adnexa may require up to six (6) extended ophthalmoscopic examinations per eye, per year.

For ICD-10-CM codes C69.20-C69.42 Malignant neoplasm of eye and adnexa; C79.89-C79.9 Secondary malignant neoplasm of other and unspecified sites; D31.20-D31.32 Benign neoplasm of eye and adnexa up to four (4) extended ophthalmoscopic examinations may be required per eye, per year.

Other conditions usually require no more than two (2) extended ophthalmoscopic examinations per eye, per year.

Extended ophthalmoscopy is a physician service (examination of the eye) commonly occurring during the global post-operative period of ophthalmic surgery.  As a physician service, it is included in the aftercare of the patient and is not separately billable.

Services exceeding these parameters will be considered not medically necessary.

• A detailed sketch must be included in the medical record and available to Medicare upon request.  The sketch attached to this policy may be used.
• The sketch should be a minimum size of 3-4″ in diameter
• All items noted must be identified (i.e., any findings such as drusen must be drawn and labeled)
• Drawings in 4-6 standard colors are preferred.  However, non-colored drawings are also acceptable.

Colors and Meanings:

RED:  Retinal arteries, retinal hemorrhages, attached retina

BLUE: Retinal veins, detached retina

YELLOW: Chorioretinal exudate, intraretinal exudate, intraretinal edema

GREEN: Opacities in media, vitreous hemorrhage

PURPLE: Flat neovascularization

ORANGE: Elevated neovascularization

BROWN: Retinal pigment epithelium or choroidal pigmentation seen through attached retina; vascular occlusion

BLUE OUTLINE FILLED WITH RED: Full thickness sensory retinal break

BLUE OUTLINE 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 OVERLYING ORA SERRATA CIRCLE ON FUNDUS CHART: Ora serrata with adjacent detached retina

GREEN OUTLINE FILLED WITH RED: Red blood in vitreous

These charts contain three concentric circles.  Inner circle represents equator, middle circle represents ora serrata, and outer circle represents region of ciliary processes.  Band between middle and outer circles is pars plana of ciliary body. Small circle in center of chart represents disc.  These draw-ings are done so that quick reference may be made and essential informa-tion can be conveyed to others.  In addition, these drawings will be used for reference in future examinations as well as helping to “think out” what is presently being encountered.

Use the optic nerve as a reference point.  Systematically examine the quadrants out to their periphery.  Special features to observe include optic nerve color, cupping, and margination; vascular caliber, pulsa-tions, tortuosity, aneurysms, and anomalies; hemorrhages, exudates, edema, and neovascularization; areas of retinitis, perivasculitis, and arteriolar or venular obliteration; pigmentary changes, hyperplasia, sparsity, and bone-spicule formation; tumors, schisis, elevation, or detachment; peripheral retinal ab-normalities; and especially a close look at the macular area for holes, cysts, edema, or degeneration.  Hemiretinal differences have been revealed through the examination of large numbers of fundi. Lattice degeneration, retinal breaks, pars plana cysts, dialysis of the young, and senile retinoschisis are more common in the temporal periphery.  In the nasal periphery, it is relatively more common to find prominent teeth, meridional folds at the ora, granular tissue, and detachment of the pars plana.