CPT 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

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


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.