Coding & Reimbursement

Supporting your EO claim

It’s one of eye care’s most common tests, so Medicare loves to audit it.

By Suzanne L. Corcoran

Extended ophthalmoscopy (EO) is a helpful tool when dealing with serious posterior segment disease, as evidenced by its frequency of use within the Medicare system; in CY 2013, ophthalmologists used this test during 17% of all eye exams that occurred on Medicare beneficiaries. Consequently, it’s important for you to understand what is needed to support reimbursement.

Q. What is extended ophthalmoscopy?

A. Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard fundoscopy of an office visit. CPT identifies it as 92225 (Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial) and 92226 (subsequent). CPT adds, “Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a non-itemized service and is not reported separately.”

92225 describes 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 92225 may be used more than once per eye for a new condition.

Q. What are the indications?

A. EO is indicated for a large number of conditions involving posterior segment pathology. It is reserved for serious retinal pathology such as retinal tear and retinal detachment. You should not bill it every time you use an indirect ophthalmoscope and make a note about the fundus. Most Medicare administrative contractors (MACs) have published local coverage determination (LCD) policies that include a list of covered diagnoses.

Q. When is EO billed?

A. Ophthalmoscopy is a required element of the eye exam for higher-level E/M codes (992x4, 992x5) and comprehensive eye codes (920x4). The chart notes for this routine ophthalmoscopy can take many forms: descriptive terms, quantitative measures of cup-disk ratio, or small sparse sketch of the fundus. A retinal drawing for EO is much more detailed, larger, commonly colored, carefully annotated, and appropriate for the serious condition depicted. Although each MACs’ LCDs contain specific documentation requirements, some points are common throughout, including:

• Documentation must be legible;

• Retinal drawing must be maintained in the patient’s record;

• Drawings should include sufficient detail, standard color(s) and appropriate labels.

The utility of the retinal drawing is apparent when the patient returns for re-evaluation of the same condition. The ophthalmologist can compare what is observed today with the prior retinal drawing. Where there is clinically significant change, the physician should make another retinal drawing to serve as a new benchmark for future comparison. If no apparent change is noted, another drawing is not needed or justified. The new drawing that reflects the clinically significant change is the support for a subsequent EO (92226).

Q. What documentation is required?

A. Most LCDs don’t specify the size of the drawing, but simply state that the drawing must be “detailed.” Some LCDs do include size requirements, usually 2½ to 3 inches or more. Experience teaches us that it is difficult to supply sufficient detail in a smaller drawing. Implicit in this requirement for EO is that the drawing cannot represent a normal fundus no matter how thorough the ophthalmoscopy.

Q. How is EO paid?

A. EO is defined as a unilateral test, so reimbursement is per eye. Due to this definition, payers assume that the service is not always needed on both eyes and will not always be billed as a bilateral service. In Q1 2015, the national Medicare allowable is $27.17 per eye for the initial exam (92225) and $25.03 per eye for the subsequent exam (92226). Local wage indices adjust these amounts in each area. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

EO is bundled with most retinal surgery codes under the National Correct Coding Initiative, and the two codes are mutually exclusive with one another. Some LCDs also state that EO is not payable on the same day as OCT (92133, 92134); a few payers also bundle EO with fundus photography (92250). EO and imaging studies performed concurrently on the same eye that contain the same information are redundant, and only the more intensive service should be billed.

Considerable regional differences exist in the frequency of this service, but in every region of the country it is flagged as an over-utilized service and is subject to frequent Medicare audits.

In a retinal practice, it is likely that EO will occur more often than the norm and attract added scrutiny.

By paying attention to the quality of the retinal drawings and the severity and progression of the disease shown, you can prevail in a challenge to your utilization pattern for EO. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.