CPT Code: 92226  Region: 02

States covered:  Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin

Title:  Extended Ophthalmoscopy for Subsequent Visits

Category
Special Ophthalmological Services

Description
Extended Ophthalmoscopy with retinal drawings (eg, for retinal detachment, melanoma) with interpretation and report for subsequent visits



Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report.  It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy.  It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy.  The examination must be used in the medical decision making for the patient.

Extended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy.

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions:

  • Malignant neoplasm of the retina or choroid
  • 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.
  • Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration
  • 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.”
  • Symptoms suggestive of retinal defect (ex: flashes and/or floaters)
  • Retinal defects without retinal detachment
  • Diabetic retinopathy (i.e., 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.
  • Experienced sudden visual loss or transient visual loss
  • Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment
  • Sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye
  • Sustained a blunt injury to the eye or pariorbita
  • Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment).  Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders.
  • 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.
  • Vogt-Koyanagi syndrome.  A condition 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.
  • Degenerative disorders of the globe
  • Retinoschisis and retinal cysts.  Patients may complain of light flashes and floaters.
  • Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision
  • Glaucoma or is a glaucoma suspect.  This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve.
  • Systemic disorders which may be associated with retinal pathology
  • High axial length myopia
  • Retinal edema
  • Metamorphopsia
  • High-risk medication for retinopathy or optic neuropathy
  • Choroidal nevus being evaluated for malignant transformation
  • Macular degeneration


Limitations:

  • Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary.  Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically necessary.
  • General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination (92002-92004) and are not separately payable, but these should still be documented in the patient’s medical record
  • If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated in the attached Appendix A, the service is not separately payable and will be considered part of a general ophthalmologic exam (92002-92014) or E&M service
  • Extended ophthalmoscopy (codes 92225, 92226) performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed
  • If the medical record does not include the interpretation and report, the extended ophthalmoscopy will be denied as not medically necessary
  • Extended ophthalmoscopy will be denied as not medically necessary when it is done in lieu of routine ophthalmoscopy unless the indication for this more extensive examination is documented in the medical record
  • When other ophthalmological tests (e.g., fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information

ICD-10 Diagnosis Codes



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.