Ophthalmology and Optometry Coding Alert

Avoid the denials and frustrations associated with reimbursement for extended ophthalmoscopy for both eyes by using modifiers correctly.

Retinologists often need to bill extended ophthalmoscopy codes 92225 (initial) or 92226 (subsequent) on both eyes, because they checked and drew both eyes. However, unless you file the claims correctly, they will be denied as duplicates. The carriers computer will think you have filed for one eye twice; this is one of the frustrations of being an ophthalmology coder .

There are three coding methods to help you gain reimbursement.

1. Code 92225. Ramona Cosme, president of Ramco Billing, an ophthalmology billing and compliance consulting firm based in Edison, N.J., says, We know that in New Jersey they want two units, so we bill it with 92225, and two in the units box. Since 92225 and 92226 are paid unilaterally, you need to state your fee accordingly, notes Cosme. When its two units, you double the fee, she says.

2. Modifier -50. Another option is to use the -50 modifier (bilateral procedure). This is required in the Medicare program in Tennessee, where Connie Ripley, billing and insurance clerk for the Charles Retina Institute, files many extended ophthalmoscopy claims. We use one unit, one line, and the -50 modifier, she says. With the -50 modifier, something which ophthalmologists are very familiar with, you dont need to bill twice. The modifier automatically signals that you have performed a procedure bilaterally and should be paid twice for it. They also double their fee submitted for the single line-item.

But patients come to the Charles Retina Institute from neighboring states as well, so Ripley knows how varied extended ophthalmoscopy billing requirements are. Arkansas wants two units and the -50 modifier. Missouri wants two units and no modifier, she explains.

And dont forget about commercial insurance companies. Its trial and error with them, says Ripley. You file it one way, and if it doesnt work, you try it another way.


3. Modifiers -LT and -RT. Finally, there are the -LT and -RT modifiers. These do not affect payment the way the -50 modifier or the units field does. But using these modifiers will erase any confusion about duplicate billing. You are clearly billing for both eyes if you have one line with 92225-LT and another with 92225-RT.

Tip: You will not get paid for extended ophthalmoscopyeither eyeif you dont have medical necessity. Medicare is quite strict about this. Even if you have medical necessity for one eye, you need it for the other as well, or you could be in trouble for filing false claims if you are ever audited.