92226_R37

Medicare does not have a local coverage determination (LCD) for an extended ophthalmoscopy for subsequent visits in your region.  The policy presented is a sample and is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.  

1.  The medical record should clearly indicate the condition being evaluated and the primary diagnosis must support the medical necessity of the procedure.  In addition, indications for extended ophthalmoscopy should be entered into the medical record on a case-by-case and eye-by-eye basis.

2.  Extended ophthalmoscopy should meet the following documentation requirements:

• A separate detailed sketch of the retina accurately representing normal, abnormal and common finding such as lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, retinal detachments, holes, tears or tumors
• All items noted on the sketch must be identified and labeled
• Optic nerve abnormalities should be drawn separately
• Drawings using 4-6 standard colors are preferred;howver, non-colored drawings are acceptable if they are clearly labeled

3.  Extended ophthalmoscopy drawings should be maintained in the patient’s medical record with an interpretation and report and the following noted: 

• Method of examination (scleral depression, 3-mirrored lens, 20 diopter lens, 90 diopter lens)
• The drug used for pupil dilation
• All posterior pole findings and a treatment plan

4.  It is recommended that patients with a glaucoma diagnosis meet the following documentation requirements for extended ophthalmoscopy: 

• A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment
• Documentation of cupping, disc rim, pallor, sloping or any pathology surrounding the optic nerve

5.  Documentation must be legible and made available to Medicare upon request

1.  Report extended ophthalmoscopy for subsequent visits with CPT code 92226.

2.  Extended ophthalmoscopy is a professional service.  Therefore, the use of modifiers for professional (-26) and technical components (TC) is not appropriate for these codes.

3.  An eye examination may be reported on the same day as extended ophthalmoscopy if it is medically necessary. 

4.  CPT code 92226 is payable with CPT codes 92012 and 92014 (established patients only).

5.  Indirect ophthalmoscopy done without a drawing is part of the general ophthalmologic examination and should not be billed separately as extended ophthalmoscopy.

6.  Routine ophthalmoscopy and biomicroscopy are part of the general ophthalmologic examination and should not be billed separately as extended ophthalmoscopy.

Medicare has determined that extended ophthalmoscopy should add clinical information that is not available from the general ophthalmologic examination and the procedure should 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 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.

RETINAL DRAWING COLOR SCHEME