More is not always better.

Extended ophthalmoscopy (CPT 92225, 92226) and imaging of the retina (CPT 92250, 92134, 92235, 92240) are overlapping services, so billers ask whether both can be reimbursed when they occur on the same day. Ophthalmologists would prefer that the answer be “yes,” but payers take a different view and say, “sometimes.” When extended ophthalmoscopy (EO) and imaging are performed concurrently, reimbursement depends on finding different information.

Medical Necessity

Some Medicare Administrative Contractors have addressed billing EO in conjunction with other imaging. The historic LCDs for both CGS Administrators¹ and National Government Services² state, “When other ophthalmological tests (eg, fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.” This is also addressed in the LCDs published by CGS,³ Wisconsin Physicians Service Insurance Corporation,⁴ and First Coast Service Options.⁵

The most recent First Coast Service Options LCD on this topic further states, “Extended ophthalmoscopy codes are reserved for the meticulous evaluation of the eye in detailed documentation of a severe ophthalmologic problem needing continued follow-up, which cannot be sufficiently evaluated by photography.”

In the same LCD, First Coast Service Options adds, “In all instances extended ophthalmoscopy must be medically necessary. It must add information not available from the standard evaluation services and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means.”

Through our chart reviews, and the audits of payers, we find that EO is often (but not always) duplicative with imaging and, therefore, should not be billed. The following vignette provides a situation where EO and imaging are both warranted.

An established patient returns for re-evaluation of mild, bilateral, open-angle glaucoma (H40.1131). At the prior visit, threshold perimetry and scanning computerized ophthalmic diagnostic imaging of the optic nerve were ordered. Prior to dilation, these tests were performed. During the dilated eye exam, the ophthalmologist notes a suspicious appearance of the peripheral retina OS. Using bilateral indirect ophthalmoscopy with scleral depression, the ophthalmologist finds a retinal tear without retinal detachment OS (H33.322) and refers the patient to a retina specialist for laser prophylaxis. A retinal drawing for the left eye is entered in the chart. The NCCI edits do not bundle 92133 with 92225, although there are limitations in many coverage policies. The physician’s claim will read as shown on the previous page.

In this case, payment for EO is not duplicative with SCODI because peripheral retina and optic nerve are distinct and the information is additive. The following vignette provides a situation where EO and imaging are duplicative, and only one is warranted.

An established patient returns for re-evaluation of severe, bilateral, open-angle glaucoma (H40.1133). During the dilated eye exam, the ophthalmologist notes an optic disc hemorrhage OS (H47.392) and orders a fundus photograph of the new finding. Additionally, a retinal drawing of the optic nerve for the left eye is entered in the chart. The NCCI edits do not bundle 92250 with 92225 yet in this case the drawing and the photograph are duplicative and the information is not additive. The physician’s claim will read as shown below.

Before billing for multiple tests, consider why each was performed and what information it provided (new or duplicative). Where multiple diagnoses are involved and imaging cannot capture the desired information, a separate charge for EO may be justified. In those cases, documentation should include a unique order, the retinal drawings and an interpretation for each test. Where multiple tests are performed for a single diagnosis or the interpretations read the same for all tests, it is difficult to argue that additive information was obtained. While non-Medicare payers are not required to adhere to the NCCI edits, most do.

Conclusion

More is not always better. Imaging and retinal drawings are valuable tools for assessing the posterior pole, yet when these tests are performed in tandem, justification for reimbursement depends on finding different information in the drawings and images. GP

References

1. CGS Administrators LCD 34399.
2. National Government Services LCD 33567.
3. CGS Administrators LCD 34061.
4. Wisconsin Physician Services LCD L34760.
5. First Coast Service Options LCD L34017.

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernadino, California.