by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 10th, 2016
||Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial|
|92226||Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent|
|92227||Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral|
|92228||Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral|
|92250||Fundus photography with interpretation and report|
The patient's medical record must contain documentation that fully supports the medical necessity for fundus photography and/or extended ophthalmoscopy for each eye, as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A copyof the fundus photographs must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves. The medical record should also document whether the pupil was dilated for the procedure.
Retinal drawings meeting the indicated specifications must be maintained in the patient’s record:
Documentation in the patient’s medical record for a diagnosis of glaucoma must include all of the following:
Documentation of the specific method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.
– LCD Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (L33467)