Ophthalmology and Optometry Coding Alert

Question: When an evaluation and management (E/M) visit and an ophthalmoscopy are performed on the same day, should I attach a modifier for both to get paid? What would be the best modifier?

Rebecca Alvarez
Retina Specialists, Corpus Christi, Texas

Answer: In regards to the Medicare program, testing services such as 92225 (ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) or 92226 (ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; subsequent) are billable in addition to office visits and do not ever require a modifier to be billed on the same day. Even during a postoperative period, testing services are always paid separately and are not considered to be part of the global surgical package. If performing 92225 or 92226 on both eyes on the same day, your carrier will require that you attach the -50 modifier (bilateral procedure) to indicate that the service was performed on both eyes.

When dealing with insurance companies other than Medicare, you may find that they often pay only for the office visit and instruct you that other services performed on that day are included in the payment for the visit. In that instance, if you are a contracted provider with the insurance company, you are obligated to adjust off the services. The only solution to this problem is to challenge the insurance company by illustrating that CPT recognizes the services with their own CPT codes and descriptions and that if they are processing a claim using CPT, they should recognize the separate services. The problem is that sometimes, this can be a long process. Many practices choose instead to use a higher level office visit code and include the additional services, such as extended ophthalmoscopy.