Raise Your Eye-Q
Coding diagnostic ophthalmological procedures requires a clear focus on anatomy.
By Nancy Clark, CPC, CPB, CPMA, CPC-I
Numerous tests assist ophthalmologists and optometrists in diagnosing and treating eye diseases. Understanding these procedures will enable you to identify medical necessity. Let’s review several of the more common diagnostic procedures and explore their coding.
Ophthalmoscopy—an examination of the back of the eye (fundus)—is part of most eye exams. In instances of known or suspected posterior segment pathology, an extended ophthalmoscopy may be required. This allows visualization of the optic disc, arteries, veins, retina, and choroid. It’s usually performed with the pupil dilated to ensure optimal visualization of the retina.
Extended ophthalmoscopy (EO) is reported with either CPT® code 92225 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial or 92226 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent.
Code 92225 is used for the initial evaluation of a stated disease process and 92226 is used for subsequent examination of the same disease. Applying this rationale, it’s possible to perform more than one initial extended ophthalmoscopy on the same eye for a different condition. There are many diagnoses to support medical necessity for this test, including retinal, choroidal, and optic nerve problems, glaucoma, neoplasms, and trauma. Medically reimbursable diagnoses may be carrier-specific, so be sure to consult the carrier’s website.
How often this test is provided depends on the patient’s diagnosis. A single interpretation is necessary to document clinically significant details of the pathology. Subsequent drawings may be medically necessary if there is a change in the extent, appearance, or size of the condition that directly affects disease management. Written interpretation and the rationale for the procedure must be included in the documentation.
The Centers for Medicare & Medicaid Services (CMS) assigns EO a bilateral indicator of 3, which indicates this procedure is unilateral and should be billed at 100 percent of the fee schedule for each eye. To bill the procedure for both eyes, a medically necessary diagnosis must be present for each eye.
A detailed retinal drawing must be present in the patient’s chart. Drawing specifications vary among carriers, but requirements usually include explicit notations of the anatomy and pathology of the fundus and periphery. The drawing’s size is usually a minimum of three to four inches in diameter. Without this documentation, EO is not billable.
Some payers will not reimburse EO when performed on the same date as other posterior segment imaging (i.e., fundus photography). Medicare will consider EO as medically necessary when performed with multiple imaging services if additional (non-duplicative) information can be provided.
Some carriers also may not reimburse EO within the global period of an ophthalmologic surgery because CMS identifies this procedure as a physician service [Professional component (PC)/Technical component (TC) indicator 0], rather than a diagnostic test. If EO is performed in the global period of an unrelated surgery, it may be appropriate to append modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
Medicare extensively audits EO codes. Frequently, the required supporting documentation or medical necessity is not present in the patient’s chart. Ensure you follow the guidelines of the Medicare administrative contractor (MAC) or commercial contractor to substantiate the service.
Example: A diabetic patient is referred to the ophthalmologist for possible retinopathy. The physician performs an EO on both eyes, which is reported with 92225-50 Bilateral procedure (or 92225-LT Left side, 92225-RT Right side, based on carrier preference). The billed amount is 200 percent of the fee schedule (100 percent for each eye). The ophthalmologist provides detailed retinal drawings and assigns a diagnosis of diabetic retinopathy for each eye.
The patient returns in three months for a follow-up EO. This subsequent EO is reported with 92226-50 (or 92226-LT, 92226-RT).
The following year, the patient presents to the ophthalmologist with a new complaint of flashes in his left eye. At this visit, an EO is performed on the left eye only and coded with 92225-LT. This is the initial EO for the flashes, and the ophthalmologist assigns a diagnosis of posterior vitreous detachment.
CPT® code 92250 Fundus photography with interpretation and report involves the use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve of the eye. Fundus photography is similar to EO in that it’s usually performed through a dilated pupil, but differs from EO in that it provides a permanent picture of the patient’s fundus that can be examined by a specialist at another time.
According to the American Academy of Ophthalmology’s (AAO’s) Preferred Practice Pattern Guidelines®, fundus photography provides objective documentation for age-related macular degeneration, primary open-angle glaucoma, and diabetic retinopathy, and is the best routine approach to establish a baseline for future comparisons. Subsequent photographs are considered medically necessary for a change in extent of the disease process, or for a change in appearance or size directly affecting management of the condition. As with most diagnostic eye tests, fundus photography usually is not reimbursed for routine screenings in the absence of signs or symptoms.
CMS designates 92250 as bilateral. There is no increase in payment for photographing both eyes, and most carriers do not require modifier 50. Fundus photography (92250) is considered mutually exclusive with scanning computerized ophthalmic diagnostic testing of the posterior segment (92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve, 92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina), and indocyanine green (ICG) angiography (92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report).
As with other diagnostic testing, the technical and professional components may be billed separately and identified by appending modifier TC Technical component or modifier 26 Professional component. When billing for the professional component, there must be a written report in the patient’s record. The photograph alone does not support the definition of the CPT® code.
Fundus photography is subject to the multiple procedure payment reduction (MPPR); payment for 92250 will be reduced when performed with another, higher-paying diagnostic procedure.
and ICG Angiography
Fluorescein angiography (FA) goes beyond imaging, using injection of an intravenous dye and serial photographs to visualize leaking from damaged vessels. FA may be used when a patient has abnormal fundus or retina findings in an eye exam, presents with symptoms such as sudden vision loss, or needs monitoring for a recurring disease such as diabetic macular edema.
CPT® code 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report is unilateral. Proper reporting varies by carrier, but most often the code is listed on a separate line for each eye, with modifiers LT and/or RT appended.
Code 92240 (ICG) refers to an angiography with indocyanine-green dye. The dye’s infrared frequencies penetrate retinal layers, producing deeper patterns of circulation than in an FA. This procedure is effective when diagnosing and treating ill-defined choroidal neovascularization, as associated with age-related macular degeneration. ICG is a valuable diagnostic adjunct to FA in evaluating many retinal conditions. As such, both procedures are reimbursable on the same day when medically indicated.
Code 92240 is a unilateral procedure. Common carrier preferences of bilateral reporting are shown in the table below.
Acceptable Forms of Bilateral Reporting
|CPT® Code||Modifier||Number of Units||Percent of Fee Schedule Billed|
|Line 1||92235||LT, RT||2||200%|
In addition to following carrier guidelines for coding, ensure the billed amount is 100 percent of the allowable for each eye examined.
You may perform 92235 as often as every eight weeks to assist in management of retinopathy. Code 92240 is usually payable once per disease process for the initial evaluation. Both procedures are subject to MPPR.
Example: An established patient presents to the ophthalmologist complaining of a sudden onset of vision loss in his left eye. There are no unusual symptoms in the right eye. The physician performs a comprehensive eye exam and orders a fluorescein angiography on the patient’s left eye. The FA shows a retinal hemorrhage.
Report 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits for the eye exam and 92235-LT for the FA. It was not medically necessary to perform the FA on both eyes; therefore, a bilateral test was not indicated. The definitive diagnosis is identified with ICD-9-CM code 362.81 Retinal hemorrhage.
Visual Field Testing
Visual field (VF) testing is used to determine defects in the field of vision and to test function of the retina, optic nerve, and optic pathways. Several automated and manual tests are available. The tests quantify the degree of visual loss as a baseline to detect future progressions. CPT® codes associated with VF are:
92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent)
92082 … intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)
92083 … extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2)
The level of detail and complexity increases with each ascending code. For example, 92081, a limited VF, can be used to report a single stimulus level test performed on a tangent screen (a black felt screen mounted on the wall). The intermediate exam, 92082, might use the Goldmann perimeter, which has two separate outer margins of vision, or isopters, plotted. The extended exam, 92083, will increase the isopters to three and can test the full limit of peripheral vision. An automated perimetry exam, such as the Humphrey visual field analyzer (in which lights appear on a white background), is commonly used for early detection of blind spots.
Per CPT®, the VF codes do not report gross VF testing, which is included in a general ophthalmologic examination. In gross VF testing, the examiner holds up and moves fingers while the patient gazes straight ahead.
Note that the codes specifically indicate unilateral or bilateral. Modifier 50 does not apply, and modifiers LT or RT are not necessary. There is no increase in payment if the procedure is performed on both eyes. As with other codes, the CPT® descriptor specifically requires a written interpretation or report in the medical record.
Many diagnoses can support the medical necessity of VF testing, including potentially obstructive disorders of the eyelid, glaucoma, optic nerve or retina disorders, unexplained visual loss, recent significant eye injury, and long-term use of certain medications.
The AAO and several MACs have published frequency guidelines, usually advising one test per year for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and more often for unusual cases or new symptoms. All three VF codes (92081, 92082, and 92083) are subject to MPPR. When performing multiple diagnostic procedures that do not have National Correct Coding Initiative (NCCI) edits, neither modifier 51 Multiple procedures nor modifier 59 Distinct procedural service is required.
Example: A new patient presents to the ophthalmologist with a complaint of visual disturbances and decreased visual acuity for one month. He has blind spots in his peripheral visual field. Family history is positive for glaucoma. A comprehensive eye exam is performed, in addition to fundus photography and an extended visual field examination.
Report 92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits for the exam, 92250 for the fundus photos, and 92083 for the visual field. The ophthalmologist diagnoses 365.11 Primary open angle glaucoma.
Neither of the diagnostic tests requires a bilateral modifier, and it isn’t necessary to designate multiple diagnostic procedures with modifier 51. MACs, however, may append modifier 51 to the lower-valued procedure on the explanation of benefits (EOB) to indicate the MPPR.
Ophthalmic A and B Scans
Ophthalmic ultrasound is used to evaluate the eye and eye socket, or orbit. Codes 76510-76519 refer to different diagnostic ultrasound scans of the eye:
76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter
76511 … quantitative A-scan only
76512 B-scan (with or without superimposed non-quantitative A-scan)
76513 … anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy
76514 … corneal pachymetry, unilateral or bilateral (determination of corneal thickness)
76516 Ophthalmic biometry by ultrasound echography, A-scan;
76519 … with intraocular lens power calculation
As defined in CPT®, an A-mode implies a 1D ultrasonic measurement procedure and a B-scan implies a 2D ultrasonic scanning procedure with a 2D display. A-scans, also called ophthalmic biometry, are generally performed prior to cataract surgery to measure the length of the eye. Ophthalmic A-scans are covered under Medicare when performed prior to cataract surgery.
Both A- and B-scans are used to identify neoplasms, foreign bodies, and inflammation in the eye. Typically, only one A- or B-scan is allowed in a 12-month period. An exception may be made when cataract surgery is postponed and a current measurement is required. These procedures are considered unilateral by CMS and are coded separately for each eye. Application of coding is similar to the table above, with each eye billed separately at 100 percent of the fee schedule.
Example: A patient and his ophthalmologist have decided to remove a cataract in his left eye and implant an intraocular lens (IOL). Prior to the surgery, the physician orders an A-scan to measure the axial length of the eyeball. The echographer calculates the necessary IOL implant power. Code 76519 identifies this procedure.
Bundling note: Per NCCI edits, CPT® code 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) is bundled with most concurrent ophthalmological diagnostic tests.