Extended Ophthalmoscopy (92225, 92226)

From time to time, we are reminded that we need continued attention to proper documentation and medical necessity requirements for extended ophthalmoscopy.  While not new, a Local Coverage Determination (LCD) from First Coast Service Options, Inc. (FCSO), the Medicare Administrative Contractor (MAC) for Florida and others, spells out in detail the requirements for 92225 and 92226.  Other MACs also have policies, but we found the FCSO LCD to be particularly succinct.  The key points:

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 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.

Documentation Requirements

Medical record documentation (eg, office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the extended ophthalmoscopy exam. The medical records must include the following:

  • The complaint or symptomatology necessitating the extended ophthalmoscopy exam
  • Notation that the eye examined was dilated and the drug used
  • The method of examination (eg, lens, instrument used)
  • A detailed drawing of the retina showing anatomy in the patient as seen at time of examination, including the pathology found and a legible narrative report of the findings
  • An assessment of the change from previous examinations when performing follow-up services (92226)
  • If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation … The physician must state the clinical indication/medical necessity for the ophthalmoscopy in the order for the exam.

Documentation in the medical record for a diagnosis of glaucoma … must include all of the following:

  • a detailed drawing of the optic nerve,
  • documentation of cupping, disc rim, pallor, and slope, and
  • documentation of any surrounding pathology around the optic nerve.

The LCD is effective 10/01/2017 and may be found here.  We strongly recommend that you regularly check your own MAC’s LCDs since they can change without notice.

As always, we are happy to you in any way with chart reviews, payer actions, and training on these or other topics.  Please contact us via one of the below links or on our “App”, Corcoran 24/7, which can be accessed via one of the links below.

www.corcoranccg.com   (800) 399-6565

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