Ophthalmology and Optometry Coding Alert

Hint: Don’t report these codes bilaterally.

Extended ophthalmoscopy (EO) is one of the most commonly reported services by eye care providers, but it’s also frequently audited. Most eye exams will include some sort of ophthalmoscopy, but payers are prone to considering them as part of the general ophthalmic exam or evaluation and management (E/M) code.

There are cases, though, where you’re justified in reporting EO separately. Check out answers to the following three frequently asked questions to make sure you’re not missing out on EOs you could rightfully report.

Question 1: When Does Ophthalmoscopy Qualify As Extended?

Answer: Any general ophthalmic examination will include a routine ophthalmoscopy. But an extended ophthalmoscopy is a special ophthalmologic service that goes beyond the general eye exam.

Caution: The general ophthalmic examination codes (92002- 92014) already include routine ophthalmoscopy, so you should not report routine ophthalmoscopy (which can include a slit lamp examination with a Hruby lens or direct or indirect ophthalmoscopy for fundus examination) separately with 92002-92014.

When an initial exam uncovers a serious retinal problem, eye care specialists then turn to extended ophthalmoscopy, which you can report with the following codes:

• 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 medical record should document whether the pupil was dilated, and which drug was used,” CMS says in Coverage Policy A56726. “All findings and a plan of action should be documented in the notes.”

Documentation must include retinal drawings and drawings showing any abnormal findings, as well as documentation about the method of examination, surrounding pathology around the optic nerve, and more, CMS notes. Some insurers require the drawings to be of a particular size, detail, and color.

If you have any documentation concerns on your EO claims, check your payer contract or call the insurer before filing.

Question 2: Can We Report EO at Every Visit?

Answer: You won’t typically report EO for every visit, unless the patient has a condition that warrants it. Insurers maintain frequency guidelines for this service.

If the patient has a condition like diabetes, the payer may reimburse you for EO up to six times per year, per eye. And when it comes to malignancies of the eye, your insurer may be more likely to pay EO up to four times per year, per eye. Most other conditions will not warrant performing and billing for this service more than twice a year per eye, according to Medicare guidelines.

However, your payers may maintain their own frequency rules around EO, so always check the most recent policy before submitting a claim for this service.

Question 3: Can We Bill EO Bilaterally?

Answer: Although the previous codes describing EO (92225 and 92226, which were deleted in 2020) were considered unilateral and therefore reported separately for each eye, that’s not the case for 92201 and 92202.

The descriptors for these codes say “unilateral or bilateral,” which indicates that you should report this code only once whether the service is performed on one or both eyes. In addition, the Medicare Physician Fee Schedule indicates that the bilateral procedure modifiers are not applicable to 92201 or 92202.