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EXTENDED OPHTHALMOSCOPY
The Rhode Island Medicare Carrier will only cover unilateral studies for CPT codes 92225 and 92226 when billed with the following ICD-9 diagnosis codes:
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.35 Central retinal vein occlusion
362.36 Venous tributary (branch) occlusion
362.52 Exudative senile macular degeneration
This is reflective of the fact that the above diagnosis codes almost always indicate unilateral disease; therefore, only one service is automatically allowed. However, if this diagnosis code is billed with another covered diagnosis code listed on the policy, then both services would be allowed. As always, these partial denials may be appealed if it is believed that bilateral drawings were medically necessary.
A covered diagnosis does not automatically mean that an extended fundus examination is medically necessary. It may be, but frequently it is not. Local Medical Review Policy RI 1998-102 explains the documentation requirements that must be met in order for CPT codes 92225 and 92226 to be allowed and paid.
1. A clearly labeled retinal drawing with detailed, color-coded retinal pathologic findings must be part of the patient’s medical record along with a notation as to the method used to perform the extended ophthalmoscopic exam. The diameter of this drawing must be at least three (3) inches or greater.
2. A serious or potentially serious retinal condition must exist to warrant this service.
3. Another method of examination must also be used (in addition to ophthalmoscopy), such as use of a fndus contacts lens, a 60, 78, or 90 diopter lens, a Hruby lens, 360 degree scleral depression, etc. This technique must also be documented in the patient’s medical record.
4. It must be clearly documented as to what prompted the need for a more detailed retinal examination and accompanying drawing to be done when an extended ophthalmoscopy examination is claimed in conjunction with other ophthalmoscopy services.
All of our Medicare policies may be directly viewed on our website at: http://www.rimedicare.org/provider/lmrp.cfm.
Outpatient Hospital Services
The Rhode Island Medicare Carrier will only cover unilateral studies for CPT codes 92225 and 92226 when billed with the following ICD-9 diagnosis codes:
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.35 Central retinal vein occlusion
362.36 Venous tributary (branch) occlusion
362.52 Exudative senile macular degeneration
This is reflective of the fact that the above diagnosis codes almost always indicate unilateral disease; therefore, only one service is automatically allowed. However, if this diagnosis code is billed with another covered diagnosis code listed on the policy, then both services would be allowed. As always, these partial denials may be appealed if it is believed that bilateral drawings were medically necessary.
A covered diagnosis does not automatically mean that an extended fundus examination is medically necessary. It may be, but frequently it is not. Local Medical Review Policy RI 1998-102 explains the documentation requirements that must be met in order for CPT codes 92225 and 92226 to be allowed and paid.
1. A clearly labeled retinal drawing with detailed, color-coded retinal pathologic findings must be part of the patient’s medical record along with a notation as to the method used to perform the extended ophthalmoscopic exam. The diameter of this drawing must be at least three (3) inches or greater.
2. A serious or potentially serious retinal condition must exist to warrant this service.
3. Another method of examination must also be used (in addition to ophthalmoscopy), such as use of a fndus contacts lens, a 60, 78, or 90 diopter lens, a Hruby lens, 360 degree scleral depression, etc. This technique must also be documented in the patient’s medical record.
4. It must be clearly documented as to what prompted the need for a more detailed retinal examination and accompanying drawing to be done when an extended ophthalmoscopy examination is claimed in conjunction with other ophthalmoscopy services.
All of our Medicare policies may be directly viewed on our website at: http://www.rimedicare.org/provider/lmrp.cfm.
Coverage Topic:
Doctor Office VisitsOutpatient Hospital Services
