Ophthalmology and Optometry Coding Alert

Question: Could you shed some light on billing 92225 or 92226 with modifier 50, RT/LT, or two units for a newborn who is in the neonatal intensive care unit (NICU)? How do you determine medical necessity for billing twice? Ohio Subscriber Answer: Both 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 (... subsequent) are inherently unilateral, so you can get reimbursement for extended opthalmoscopies (EOs) performed on both eyes provided the ophthalmologist shows medical necessity for both. You must report ICD-9 codes illustrating medical necessity for each eye. Don't assume that both eyes have the same diagnosis. Consult your insurer's policy for diagnosis codes that support medical necessity. Always code diagnoses based on the MD's documentation. The range of accepted codes is pretty wide. For instance, insurers may accept 362.83 (Retinal edema) and 377.00 (Papilledema, unspecified) to prove medical necessity [...]