92226_R24

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 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
• 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 may require up to six (6) extended ophthalmoscopic examinations per eye, per year. (See list below)
• For ICD-10-CM codes C69.41-C69.42, C69.21-C69.22, C69.31-C69.32, C79.89, D31.21-D31.22 and D31.31-D31.32, 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

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

• The diagnosis code(s) must best describe the patient’s condition for which the service was performed.  For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
• 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.
• A subsequent ophthalmoscopy will not be reimbursed on the same day for the same eye by the same provider.  If a subsequent ophthalmoscopy is performed on different eyes modifier RT and LT should be reported to indicate that the service 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)
• The initial extended ophthalmoscopy code (92225) may be billed if the patient has had extended ophthalmoscopy (of the same eye) by the same physician/physician group within the last three (3) years
• Indirect ophthalmoscopy done without a drawing may not be billed separately and is part of a general ophthalmologic exam (92002-92014)
• Acceptable places of service are office, assisted living facility, urgent care, inpatient hospital, outpatient hospital, emergency room, and skilled nursing facility, nursing facility, custodial care facility, and independent clinic

Medicare has determined that extended ophthalmoscopy should add clinical information that is not available from the general ophthalmologic examination and the procedure must provide information that will affect the treatment plan.

If other diagnostic tests, such as fundus photography, fluorescien angiography or ophthalmic ultrasound have been performed, extended ophthalmoscopy should not be utilized unless it can provide non-duplicated additional information.

Extended ophthalmoscopy should not be routinely used on both eyes of every patient on all visits.

This Medicare carrier has no specific utilization guidelines for extended ophthalmoscopy.  In the absence of specific utilization guidelines, optometrists and ophthalmologists 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.