There are 2 new Current Procedural Terminology (CPT) codes for extended ophthalmoscopy effective January 1, 2020. The codes are radically different from prior ones in that the code selection is based on anatomic areas of the eye and disease entity.
- 92201: Ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral
- 92202: Ophthalmoscopy, extended, with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral
The CPT manual states that 92201 and 99202 should not be reported in conjunction with 92250 (fundus photos). Glaucoma services are coded using CPT code 92202. The national average reimbursement is $16.24.
Tips for Using the New Codes
- The codes are unilateral/bilateral, signifying that payment is the same whether 1 or both eyes are tested.
- There is no longer differentiation between initial and subsequent services.
- A retinal drawing is required for each eye (see excerpt below). There is a sample drawing in the CPT manual. You may be surprised by the amount of detail required for the drawing, which should not be a computerized sketch cut and pasted from the EMR. Be sure to check with your Medicare Administrative Contractor for new Local Coverage Determinations (LCDs) or revisions of current policies. If there are none, then use the one from NGS Medicare as a guideline.
- Interpretation and report is required for each eye. Instructions are available at www.rivaleeasbell.com .1
- If both codes are performed together on the same day, only 1 service can be billed. They cannot be unbundled under the National Correct Coding Initiative (NCCI).
- The NCCI bundles for CPT codes 92201 and 92202 can be unbundled neither with each other nor with 92250 (fundus photos).
- Medical necessity issues are usually found in the LCD, whereas the coding instructions are found in the separate Coding Article.
National Government Services Instructions
The following guidelines are quoted directly from the National Government Services Coding Article that accompanies the LCD on extended ophthalmoscopy, LCD L33567.2 Bold font below has been added here for emphasis:
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 meeting the specifications indicated in the attached Appendix A of this article 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.
- Documentation in the patient’s medical record for a diagnosis of glaucoma (ICD-10-CM codes H40.001-H40.152 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.
- Extended ophthalmoscopy is a physician service (examination of the eye) commonly occurring during the global postoperative 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. GP
- Asbell RL. Special ophthalmologic diagnostic tests interpretation & report requirements. Riva Lee Asbell Associates Website. https://www.rivaleeasbell.com/wp-content/uploads/Special-Ophthalmologic-Diagnostic-Tests.pdf . Accessed April 19, 2020.
- Ophthalmology: posterior segment imaging (extended ophthalmoscopy and fundus photography. Centers for Medicare and Medicaid Services website. https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56726&ver=17&Cntrctr=297&ContrVer=1&CntrctrSelected=297*1&DocType=Active&bc=AAABAAIAAAAA& . Accessed April 19, 2020.