Print | ShareCPT Code: 92226 Region: 10
States covered: North Carolina, South Carolina, Virginia, West Virginia
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 with a detailed drawing. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression.
It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina, macula, fundus and periphery (large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination) with interpretation and report. The examination must be used for medical decision making.
An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions:
a. Malignant neoplasm of the retina or choroid
b. Retained (old) intraocular foreign body, either magnetic or nonmagnetic.
c. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration
d. 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.”
e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters)
f. Retinal defects without retinal detachment
g. 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
h. Sudden visual loss or transient visual loss
i. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment
j. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye
k. Blunt injury to the eye or adnexa
l. 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
m. 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
n. Vogt-Koyanagi-Harada 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.
o. Degenerative disorders of the globe
p. Retinoschisis and retinal cysts-patients may complain of light flashes and floaters
q. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision
r. Glaucoma or is a glaucoma suspect-this may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve
s. Systemic disorders which may be associated with retinal pathology
t. High axial length myopia
u. Retinal edema
v. Metamorphopsia
w. High-risk medication for retinopathy or optic neuropathy
x. Choroidal nevus being evaluated for malignant transformation
y. Macular degeneration
Limitations
If the study is performed as a screening service, it is not covered by Medicare.
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.
ICD-10 Diagnosis Codes
The performance of extended ophthalmoscopy for specific conditions may be performed if reasonable and necessary to make clinical decisions in the treatment of the condition.
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 meeting the indicated specifications must be maintained in the patient’s record.
- There must be a separate detailed sketch, with a minimum size of approximately 4 inches in diameter (retina to the periphery or optic nerve margin)
- All items being documented must be clearly identified and labeled
- An extensive scaled drawing must accurately represent normal, abnormal and findings of interest in a given patient 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 must include all of the following:
- Optic nerve abnormalities should be documented in a separate drawing from ANY in the retina, and should meet the above size requirements. For example: cupping, disc rim, pallor and slope
- Any pathology surrounding the optic nerve
Documentation of the specific 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.
All findings and a plan of action should be documented in the patient’s medical record supporting the medical necessity for the test(s).
1. Report extended ophthalmoscopy with CPT code 92226 for subsequent visits.
2. General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination. These codes are included in and are not separately payable when an extended ophthalmoscopy code is billed, but these should still be documented in the patient’s medical record.
3. If extended ophthalmoscopy is done without a drawing or does not meet indicated standards, the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service.
4. 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. This circumstance can be indicated by reporting a modifier -76 or -79 depending on the date of service.
This Medicare carrier has no specific utilization guidelines for extended ophthalmoscopy. In the absence of specific utilization guidelines, providers should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of a medical practice.
Services that exceed the accepted standards of a medical practice may be deemed not medically necessary.