Billing Extended Ophthalmoscopy

Every year we are faced with changes in the billing department and 2020 was no exception. Two major eyecare codes - 92225 and 92226 - were discontinued and "replaced" with 92201 and 92202. I use the word replaced tentatively, since neither code has the same old meaning. Let's look into these codes and what we can do to make sure we get paid for the procedures.

The Definition

92201 Opthalmoscopy, extended; with retinal drawing and scleral depres­sion of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral [1].

92202 Ophthalmoscopy, extended; with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral [2].

What this means for billing

As we can see from the definitions, 92202 doesn't follow 92201 the way 92226 was subsequent to the initial 92225 procedure; in fact, they don't form any sequence. Rather, their difference is primarily in the part of the eye that the procedure is performed on. Retinal diagnoses would match up with 92201 while 92202 would go with macular and optic nerve pathologies. Of course, some pathologies, such as diabetic retinopathy, might overlap, so it would be up to the doctor to decide whether 92201 or 92202 best reflects the manifestation of the diagnosis. It's also important to note that 92201 requires scleral depression - a special technique used to examine the very outer edges of the retina - to be performed. This requirement is both new and unique; the old ophthalmoscopy codes did not specify which technique to use. As with any new CPT codes, it's a good idea to pay attention to medical record documentation specifics, so you can be prepared come audit time.

Modifiers and other big little details

It's also important to keep in mind that as per Medicare’s National Correct Coding Initiative (NCCI), 92201 and 92202 are mutually exclusive of fundus photography, 92250. While this was true of 92225 and 92226, it was possible, in cases of medical necessity, to get reimbursed for both extended ophthalmoscopy and fundus photography with a -59 modifier. However, based on our recent experimenting, the -59 modifier does not work in unbundling 92250 from 92201 and 92202.

Since we're talking modifiers, it's worth mentioning that the answer to whether or not 92201 and 92202 require eye-specific modifiers lies in the CPT codes' definition. "Unilateral or bilateral" in the code description means, in plain English, that it doesn't matter if the procedure is done on one eye or both; reimbursement will be for a single unit. RT-, LT-, and -50 modifiers are not appropriate for these types of CPT codes. Predictably, the average reimbursement for the new extended ophthalmoscopy codes is lower than what it was before with 92225 and 92226.

As an afterthought...

The introduction of new codes can be frustrating, often because there's not enough knowledge about all the nuances. A lot of times, it comes down to a trial and error of sorts, especially when we're dealing with commercial insurances. Don't be discouraged by initial denials - it's not uncommon for insurance systems to reject new codes even when you seemingly billed everything correctly. (I've seen a certain major insurance asking for "correct" modifiers for 92201 and 92202; only recently they stopped treating them as bilateral 92225 and 92226!) Just be consistent, pay attention to those EOB's, keep notes, and follow up if you do notice any rejections.

Sources:

1,2. Vicchrilli Sue, “92201 and 92202—Meet the New Codes for Extended Ophthalmoscopy,” AAO, February 2020, accessed July 11, 2020, https://www.aao.org/eyenet/article/meet-the-new-codes-for-extended-ophthalmoscopy#disqus_thread