When Do You Extend Your Ophthalmoscopy?


I was recently discussing extended ophthalmoscopy (EO) with a new graduate. I asked him if he ever encountered a situation in school when it would have been appropriate to bill for EO. Before I give you his answer, I want to preface this by saying that I have a great deal of respect for the level of his clinical knowledge, education and training. But unfortunately, like many ODs, his billing and coding training mostly included what he could pick up from discussions or as an aside in another class during school, rather than a prescriptive training program. His answer was:

"Yes, whenever we have had to refer the patient to a retinal specialist."

I had to dig deeper into this reasoning so I asked where he heard that a referral to a retinal specialist warrants billing EO. He told me that he learned it from a primary care OD he recently completed his final externship with. I assured him that there was nothing in the CPT definition for EO about "referral to a retinal specialist" and then discussed the correct use of EO (below), which is likely a much more commonly billed code when used appropriately than it would likely be if it were used only when referring to a retinal specialist!

Unfortunately, this is how many bad habits are started, with one person telling another that they do it one (incorrect) way and thinking that since they get paid when they bill it, that their rational was correct!

 

One area specifically that will increase the risk of audits is billing EO. That should not, however, deter a practice from billing EO, it simply means that we need to understand when to use it and what is required.

It is also important to remember that routine ophthalmoscopy is a part of both 920XX and 992XX codes whenever it is indicated and should not billed separately. However, EO is a detailed exam and drawing of the retina and/or vitreous that extends beyond the “routine” ophthalmoscopy that is contained in the CPT definitions of an office visit code (either 920XX or 992XX). Therefore, when vitreoretinal conditions require an examination greater than what occurs for routine ophthalmoscopy, EO is indicated.

While most carriers have their own Local Coverage Determinations (we will discuss these in a future blog), examples of conditions where EO would typically be indicated and paid appropriately may include:

  1. Retinal and choroidal neoplasms

  2. Posterior chamber inflammation

  3. Peripheral retinal conditions (breaks, lattice, schesis)

  4. Macular conditions

  5. Optic nerve conditions

 

Coding

There are two CPT codes that describe extended ophthalmoscopy both require a retinal drawing with interpretation and report:

  1. 92225 (initial)

  2. Is billed when there is the initial evaluation of a disease

  3. Example: a patient presents with flashes of light and on examination there is lattice and a vitreoretinal tuft that is documented

  4. 92226 (subsequent)

  5. Is billed when there is a follow up evaluation of the same problem that has progressed from the initial extended ophthalmoscopy

  6. Example: the patient returns for a follow up 2 weeks later and now has a partial PVD with no retinal breaks and VR tuft resolved

Documentation

Each carrier may require specific documentation for reimbursement of EO, but in the CPT definition the general requirements include:

  1. A detailed vitreoretinal drawing with sufficient detail (sometimes specific sizes are required), standard colors, and/or appropriate labels to specifically illustrate the pathology and location.

  2. The drawing should be included in the patient’s record and should be legible.

  3. For reimbursement of subsequent EO there must be documentation of change in the condition which would justify a subsequent evaluation.

Also ensure that the interpretation and report includes:

  1. What techniques were used when performing EO (i.e. scleral depression, goldmann 3 mirror)

  2. Diagnosis

  3. Comparison to previous tests (if available)

  4. How the test will impact the management of the patient

 

Incorporating EO Into Clinical Practice

In our practice, if we are monitoring a pathology that we can evaluate and monitor with a fundus photograph, we prefer to use a photograph rather than a drawing. We will utilize EO for situations where the pathology is too far peripheral to obtain a photograph or does not photograph well like an incomplete PVD.

I am excited to announce a new course: EyeCode Practice Enhancer! It will be available in July 2017 and provides short (20 minute) daily videos, text and calculators for clinicians to more completely understand the VALUE of the services they provide and maximize practice revenue.

Have a great week! - Chris