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Common Codes for the Retina

We need only a few codes for the retina, so be sure they are medically necessary.
Laurie Sorrenson, O.D. Edited by John Rumpakis, O.D., M.B.A., Clinical Coding Editor

10/21/2009

Optometric practice calls for just a handful of commonly used codes for the retina:

• 92081 to 92083 (Visual field examination, unilateral or bilateral). CPT codes 92081, 92082 and 92083 are used for visual field testing listed in increasing sensitivity; 92083 is usually used for full threshold tests (i.e., 30-2). CPT defines this test as unilateral or bilateral, and it should be reported the same way whether it is performed on one or both eyes: Always report the units as 1, with no price adjustment for unilateral or bilateral. An interpretation and report of the data must also be included.

• 92135 (Scanning computerized ophthalmic diagnostic imaging [SCODI] with interpretation and report, unilateral). SCODI is a unilateral test, so if you perform the procedure on both eyes, you must report that you performed the test twice by one of two methods: You may use modifier -50 and report it on a single line and units of 2 while doubling your fee, or you can use the modifiers RT and LT to designate right and left eye. I prefer using the RT and LT modifiers for several reasons. One, it’s easy to make two different codes in your billing software and just mark them both on your routing slip, which creates two line items on your claim. That way, you’re sure to get paid correctly for both eyes. Second, by using RT and LT, anyone in your office—front desk receptionist, optometric assistant or insurance specialist—knows exactly what procedure you did, which eye(s) you evaluated, and exactly what procedure(s) you’re billing for.

• 92250 (Fundus photography with interpretation and report). Fundus photography is used to compare and track changes in the retina. It can assist you with treatment and management decisions. Fundus photography is usually not covered for documenting the existence of a condition, but is used as a baseline and to monitor change or to confirm stability. The frequency of subsequent fundus photographs should be determined by “medical necessity” and clearly documented in the medical record. 

In most areas of the country, third-party payers don’t cover routine (screening) fundus photography because they don’t consider screening photos to be medically necessary. Screening photos should not be assigned CPT code 92250, but should be associated with the Healthcare Common Procedure Coding System (HCPCS) level II code S9986, which is defined as “Not medically necessary service.” Also, be aware that simply finding pathology on a screening photo does not make that screening photo a “medical photo” that is billable to a carrier. Simply put: Once a screening photo, always a screening photo. Upon further physical examination of the patient, if another photo is medically necessary, then it should be performed and appropriately noted in the medical record. 92250 is a bilateral code; you don’t need a -50 modifier or the RT and LT modifiers. However, in many areas in the country, if this test is performed on only one eye, you may have to indicate it with the RT or LT modifier and reduce your fee. Refer to your specific carrier guidelines for further detail on the prevailing rule applicable to your practice.

A couple of other points: 92250 (Fundus photography, bilateral) and 92135 (Scanning laser, unilateral) are considered mutually exclusive under the National Correct Coding Initiative (NCCI), so don’t bill for these for the same patient on the same day. Additionally, these special ophthalmological tests require an interpretation and report in the medical record. Many carriers are now recouping the entire code reimbursement if the interpretation and report is absent in the medical record.

• 92225 (Extended ophthalmoscopy, initial), 92226 (Extended ophthalmoscopy, subsequent). We’ll cover these complex codes in detail in a future column.

Please send your comments to CodingAbstract@gmail.com


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