Optometry Coding & Billing Alert

Published on Fri Aug 08, 2003 PDF

Don't boast about your coding skills before brushing up on your bilateral extended ophthalmoscopy rules - you could find yourself blushing when you bill for two eyes and get paid for only one.
 
Extended ophthalmoscopies - 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) and 92226 (... subsequent) - are inherently unilateral and billable on a "per eye" basis, as long as there is documented evidence of medical necessity for each eye.
 
First, report ICD-9 codes illustrating medical necessity for each eye in which EO is performed. Don't assume both eyes have the same diagnosis, says Paula Thomas, CPC, coding specialist in Chattanooga, Tenn. "You don't necessarily need different diagnoses for each eye, but they do have to both demonstrate medical necessity for the EO," so check you local carrier's policy for verification of acceptable ICD-9 codes. And if the diagnosis is diabetic retinopathy, each eye may have different manifestations, such as more hemorrhaging or more macular edema in one eye, but they have the same diagnosis, she explains.
 
Next, you have to determine how the carrier wants bilateral EOs to be reported. This applies to all carriers because even Medicare has been unsuccessful in devising one policy for all Medicare carriers.
 
Some carriers will require you to submit 92225 or 92226 with modifier -50 (Bilateral procedure) - NY Empire Medicare Services is one of them. Thomas says her practice uses the -50 modifier for bilateral EOs if both eyes have the same diagnosis and the carrier's bilateral EO guidelines instruct coders to use modifier -50.
 
Other carriers, like Georgia Medicare, will apply the 200 percent payment adjustment for bilateral extended ophthalmoscopies if you report the codes on separate lines with modifier -RT (right) and -LT (left), so each charge can be allowed full reimbursement.

And still others, though they may be few, prefer that you bill the CPT code with a 2 in the units field. Locating the LMRP for your carrier and finding out how they process bilateral EOs is a crucial step in correct EO coding.