Ophthalmological testing and examination demand

Ophthalmological Testing and Examination Demand Detailed Documentation Ophthalmoscopy is Considered a part of the E/M It has been noticed that claims with extended ophthalmoscopy codes (92225- 92226) are most frequently audited and denied by payers.

Almost all eye examinations comprise of ophthalmoscopy. That is the reason, payers most likely consider them to be a part of the general ophthalmic exam or E/M code. However, in some cases, when the documentation justifies the billing, ophthalmoscopy codes can be reported separately.

As per Aetna’s Clinical Policy, a repeat extended ophthalmoscopy is medically necessary in cases where there is a change in signs, symptoms or presenting complaints. The policy also classifies some indications for which, extended ophthalmoscopy with detailed retinal drawing, is considered experimental and investigational, because its effectiveness has not been established.

Extended Ophthalmoscopy is Beyond the Routine Eye Exam Extended Ophthalmoscopy is a widely performed screening procedure for diabetic retinopathy which is one of the 6 most common eye problems. General ophthalmic examination includes a routine ophthalmoscopy (92002-92014). These codes are not to be reported as a separate service with 92002-92014. Routine ophthalmoscopy can also include slit lamp test either with a Hruby lens or with direct ophthalmoscopy performed to examine the fundus. Codes for ophthalmoscopy are unilateral codes. If the medical records indicate that the test was performed in both eyes, then either of the two ophthalmology procedure codes for extended ophthalmoscopy (EO) must be reported with modifiers LT-RT or 50. In this particular scenario, documentation of medical necessity must support bilateral billing.

Case Study 1: An obese female patient visits her doctor with headaches, reduced vision in right eye, vague soreness and variable blur.

Routine ophthalmoscopic examination indicates elevated disc. The ophthalmologist performs extended ophthalmoscopy with a Volk 78 lens, which reveals papilledema.

What CPT® and ICD code will you report?

Include Detailed Documentation for Extended Ophthalmoscopy Standard documentation is usually sufficient when routine ophthalmoscopy codes are billed. However, for EO claims, detailed, extra, as well as additional documentation with interpretation and report is required. The records must also include documentation of the reason for the extended exam as well as the procedure used. The claims would definitely be better off with a color drawing of the retina, even if only red and blue colored pencils are used. It is always a good idea to check the payer contract when in doubt.

How is Intermediate Exam Different from Comprehensive Exam?

A new or existing condition, complicated by a new problem should be reported with 92002 for a new patient or 92012 for an established patient. An evaluation of the complete visual system and treatment should be reported with ophthalmology CPT® codes 92004 for a new patient or 92014 for an established patient. As per an AAPC newsletter, individual payers usually specify guidelines for reporting either ophthalmology CPT® codes 92002-92014 or E/M codes 99201-99215. Generally, ophthalmology services codes focus exclusively upon the eye/eyes. Documentation requirements for codes 92002-92014 are less demanding for these codes as compared to E/M service codes.

To report CPT® codes 92004 and 92014, the evaluation of the complete visual system and treatment may have been performed over the course of one or more visits.

Case Study 2: A new patient with complain of blurred vision visits an ophthalmologist, who performs a comprehensive examination of both eyes. Visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure are checked. The treatment decided was continued monitoring of the condition with no treatments. CPT® 92004 must be used because this is E/M is strictly an examination of the eyes’ function.

Case Study 3: A patient with chronic blepharitis visits his doctor for a new foreign-body sensation in his eye. While explaining his complaints, he mentions recurring headaches. A comprehensive exam done four months ago was unremarkable, therefore, the doctor did not perform another detailed exam in this visit. A slit-lamp exam indicated that a lash rubbing the cornea is causing the pain.

Determination of refractive state indicated a significant increase in hyperopia, that explained the recurring headaches. In this scenario, an E/M code can be reported as long as the standard of documentation for the E/M codes are met. Ensure that the date of onset, frequency and duration of symptoms, level of discomfort, progress of the condition, and other details defined in the E/M codes are documented.

What if there are No Complaints?

Even if the patient has no complaints, and a medical problem is diagnosed in the visit, primary diagnosis for the visit will be routine visit and secondary diagnosis will be the newly diagnosed medical condition. General ophthalmological services CPT® codes 92002-92014 should be billed for the examination. Most vision plans expect ICD-9 code V72.0 (Special investigations and examinations; examination of eyes and vision) to be the primary diagnosis.

Case Study 4: A patient comes for a routine eye exam. The doctor discovers glaucoma. Routine ophthalmological examination codes S0620 or S0621 can be billed depending on the documentation and V72.0 will be the primary diagnosis. Secondary diagnosis code will be the glaucoma code (365.xx). If the patient is asked to return for additional diagnostic tests such as visual field examination (9208192083 ) and gonioscopy (92020), these codes must be associated to the glaucoma diagnosis.

Will you Append Modifier 25 to Override Bundle?

CPT® code 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) can be reported along with comprehensive eye exam codes 92004 and 92014 without appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Though comprehensive eye exam 92004 or 92014 includes routine ophthalmoscopy, extended ophthalmoscopy is not included. Therefore, 9225 or 9226 can be billed separately even without a modifier. Some claims may still be denied because some carriers have a long-time edit for extended ophthalmoscopy when billed with 92014. In such a case, an appeal may be submitted with proof of medical necessity along with intermediate-level eye code or E/M code instead of the comprehensive eye code.

Helpful Hint: In case modifier 25 is appended, it should be with the eye exam code or the E/M code, not to the procedure code like 92225.

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