Print | ShareCPT Code: 92226 Region: 05
States covered: Florida, Puerto Rico, Virgin Islands
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 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.
ICD-10 Diagnosis Codes
Medical record documentation (eg, office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the extended ophthalmoscopy exam. The medical records must include the following:
- The complaint or symptomatology necessitating the extended ophthalmoscopy exam
- Notation that the eye examined was dilated and the drug used
- The method of examination (eg, lens, instrument used)
- A detailed drawing of the retina showing anatomy in the patient as seen at time of examination, including the pathology found and a legible narrative report of the findings
- An assessment of the change from previous examinations when performing follow-up services (92226)
If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the ophthalmoscopy exam results and interpretation, along with copies of the ordering/referring physician’s order for the ophthalmoscopy. The optometrist/ophthalmologist must state the clinical indication/medical necessity for the ophthalmoscopy in the order for the exam.
Documentation in the medical record for a diagnosis of glaucoma must include all of the following:
- A detailed drawing of the optic nerve
- Documentation of cupping, disc rim, pallor, and slope
- Documentation of any surrounding pathology around the optic nerve
The usual payment adjustment for bilateral procedures does not apply to codes 92225 and 92226. Do not report these codes with modifier –50. When medical necessity supports providing this service on both eyes, report codes on separate lines and append the appropriate modifier to designate left (LT) or right (RT) eye. This will prevent system errors for duplicate billing and each code will be allowed full reimbursement.
CPT code 92226 should be billed for subsequent extended ophthalmoscopy evaluations.
Reimbursement for an ophthalmoscopy; subsequent (CPT Code 92226) will not be made on the same day for the same eye by the same provider. If a subsequent ophthalmoscopy (CPT code 92226) is performed on different eyes, modifier RT and LT should be reported to indicate that the service were performed on different eyes.
Code 92226 is a unilateral codes and must be submitted with a site modifier (LT, RT, or 50). Only one of these modifiers may be billed on a claim line. Bilateral services must be billed with a 50 modifier, rather than RT and LT on the same line.
Ophthalmoscopy is classified as a professional service. Therefore, the use of modifiers for professional or technical components (26, TC) is not appropriate for these codes.
Code 92226 is payable with 92012 and 92014.
Routine ophthalmoscopy is part of an ophthalmologic service and is not reported separately.
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.