Coding and Reimbursement
Extended Ophthalmoscopy
Here's what to watch for when filing this type of claim.

BY SUZANNE L. CORCORAN, COE

Extended ophthalmoscopy is a de-tailed examination 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 is a non-itemized service and is not 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.

Q: What CPT code applies to this test? Two codes apply: 92225 (Ophthal-moscopy, extended with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 (subsequent). 92225 is used for the initial evaluation of disease; 92226 pertains to repeated, or subsequent, evaluation of the same problem, made worse by progression of the underlying pathology.

92225 may be used more than once for ophthalmoscopy done on the same eye, if you perform another initial extended ophthalmoscopy for a new condition.

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

• endophthalmitis
• retinal and choroidal disorders, including neoplasms
• optic disc disorders.

Note that extended ophthalmoscopy is reserved for serious retinal pathology. The procedure should not be billed if you report no findings.

Q: What documentation is required to support claims for extended ophthalmoscopy? Although each Medicare carrier's published policies contain specific documentation requirements that are not always identical, some points are common throughout:

• A retinal drawing is a necessary component of the documentation. The drawing should include sufficient detail, standard color, and/or appropriate labels.
• The retinal drawing must be maintained in the patient's record.
• Documentation must be legible.

Most LMRPs simply state that the drawing must be "detailed," but some do require that the drawing be at least 2 to 3 inches in diameter. (It's difficult to document sufficient detail in a smaller drawing.)

To be reimbursed for subsequent extended ophthalmoscopy (92226) you must also include evidence of change (e.g., worsening or progression) that warrants repeated examination.

Q: What are reimbursement amounts for this test? 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.

Q: Can we be paid for extended ophthalmoscopy with an office visit or with other tests? Extended ophthalmoscopy is not 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.

Q: What is normal utilization for this test? Medicare utilization rates for claims paid in 2000 show that extended ophthalmoscopy was performed with about 12% of eye exams, although this rate varies in different regions of the country. However, 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 very important.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800)399-6565 or via email at scorcoran@corcoranccg.com.