Coding Q & A
Coding Extended Ophthalmoscopy
Answers to common questions about this detailed exam.

What is extended ophthalmoscopy?
Answer: Extended ophthalmoscopy is a detailed exam and drawing of the fundus that goes beyond the standard funduscopy of an office visit. (In contrast, according to CPT, "Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It's a non-itemized service and isn't reported separately.")

Extended ophthalmoscopy is indicated for a wide range of posterior segment pathology when the level of examination is greater than that required for a routine ophthalmoscopy.

What CPT code applies to this test?
Answer: Two CPT codes apply: 92225 (for ophthalmoscopy, extended with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report, initial) and 92226 (subsequent). Code 92225 pertains to the initial evaluation of a disease, while 92226 involves the repeated, or subsequent, evaluation of the same problem made worse by progression of the underlying pathology.

Sometimes you may use 92225 more than once for ophthalmoscopy you perform on the same eye. Even though you've already performed 92225, it's possible to do another initial extended ophthalmoscopy for a new condition.

What justifies reimbursement for ophthalmoscopy?
Answer: Most Medicare carriers have published local medical review policies (LMRPs) that include a unique list of diagnoses that justify extended ophthalmoscopy. Some common examples include:

• neoplasms of the retina and choroid
• endophthalmitis
• retinal and choroidal disorders
• optic disc disorders.

Note that extended ophthalmoscopy is reserved for serious retinal pathology. For that reason, the procedure won't be reimbursed if you report no findings.

What documentation do you need to support claims for extended ophthalmoscopy?
Answer: Although each Medicare carrier's published policies contain specific documentation requirements that aren't always identical, some points are common throughout. They are:

• A retinal drawing that includes sufficient detail, standard color, and/or appropriate labels.
• Maintain the retinal drawing in the patient's record.
• Make sure that documentation is legible.

Most LMRPs simply state that the drawing must be "detailed," although some do include size requirements -- usually that the drawing must be at least 2 to 3 inches in diameter -- because it's difficult to document sufficient detail in a smaller drawing.

To get reimbursed for subsequent extended ophthalmoscopy (92226) you must also include evidence of a change in the patient's condition (e.g., worsening or progression) that warrants a repeated examination.

What are the reimbursement amounts for this test?
Answer: Extended ophthalmoscopy is defined as a unilateral test. In 2002, the national Medicare fee schedule allows $22.44 per eye for the initial exam (92225) and $20.27 per eye for the subsequent exam (92226). These amounts are adjusted by local wage indices in each area.

Can we get paid for extended ophthalmoscopy with an office visit or with other tests?

Answer: Extended ophthalmoscopy isn't bundled with any other services under the National Correct Coding Initiative (NCCI), although some carriers' local policies state that extended ophthalmoscopy isn't payable on the same day as scanning laser ophthalmoscopy (92135). A few carriers also bundle extended ophthalmoscopy with fundus photography and with comprehensive and complex exams.

What is the normal use for this test?
Answer: Medicare utilization rates for claims paid in 2000 show that extended ophthalmoscopy was performed about 12% of the time. That is, for every 100 eye exams performed on Medicare beneficiaries, Medicare paid for this test 12 times. Note that this service is billed per eye, and the 12% represents tests, not patients.

Different regions of the country show considerable differences in the frequency with which doctors perform this test.

But regardless of the region you practice in, extended ophthalmoscopy is flagged as an overutilized service, and it's subject to frequent Medicare audits. For that reason, documentation of the test and its medical necessity are even more important for this test than for other services.

SUZANNE CORCORAN IS VICE PRESIDENT OF CORCORAN CONSULTING GROUP. REACH HER AT (800) 399-6565 OR AT SCORCORAN@CORCORANCCG.COM.

If you have a coding question you'd like answered, send it to Terri Goshko, c/o Optometric Management, 1300 Virginia Drive, Suite 400, Ft. Washington, PA 19034. E-mail goshkotb@boucher1.com.