Reimbursement Tips for Extended Ophthalmoscopy
Published on Thu Apr 01, 1999
Extended ophthalmoscopy92225 for the first retinal drawing, and 92226 for subsequent drawingsis a potentially lucrative code in the Medicare program, one which may pay more than the accompanying office visit, according to Mary Pat Johnson, COMT, senior consultant with the Corcoran Consulting Group, a San Bernardino, CAbased ophthalmology reimbursement consultant. If you do both eyes for a diabetic, its about $75, says Johnson. For that reason, Medicare wants to make sure you do everything that needs to be donethe drawing, the interpretation and the report. Medicare considers this code to be highly overutilized, she explains. So they will make sure your drawings are what they should be.
What is Required
The drawing specifications are not stipulated by the Health Care Financing Administration (HCFA) as a national policy. Therefore, each local Medicare carrier determines what the specifications are in their jurisdiction. In many carrier areas (notably the northeastern region of the United States), the drawing requirements make this a time-consuming process, and thats why a lot of general ophthalmologists arent billing it anymore, Johnson says.
It takes a lot of time to draw the pictures for carriers in those regions; you could probably see four patients during the time it takes you to do one ophthalmoscopy. And, depending on your carrier, you may be required to draw a picture that is four inches in diameter, with different colored pencilsperhaps three, perhaps more. Some will allow you to use black ink, but you must label everythingincluding normal anatomy. They want all the anatomy, with the pathology, on the drawing, she explains. And usually, the physician cannot have preprinted circles with preprinted anatomy already drawn. You may have the preprinted circle, but not the preprinted anatomy.
The drawing, along with the report, just goes in the chart. But, upon request, you have to produce it, says Johnson. Some ophthalmologists do the ophthalmoscopy without the picturethey look at everything, but just take notes, she adds. Yet, this disqualifies the service from billing codes 92225 and 92226.
Finally, in order to use these codes there must be a disease. You may have a beautiful drawing of a healthy eye, but it wont get paid, says Johnson.
A Necessary Service; Medicare
Extended ophthalmoscopy is a necessary service, says Paul Fernandes, billing manager for Long Island Vitreal Retinal Consultants, a six-ophthalmologist practice in Great Neck, NY. Our perspective is that a retina specialist cannot do his job without extended ophthalmoscopy, says Fernandes.
He concedes that there is a prevailing wave of payers which say, If youre going to do a consult, we wont pay for the ophthalmoscopy. But Fernandes believes in fighting this philosophy. Extended ophthalmoscopy needs to be done, especially for retina and vitreous problems, he maintains.
Interestingly, insurance companiesand, [...]
