Optometric Billing-92225-Ophthalmoscopy Extended w retinal drawing - Initial-Acceptable DX Codes

We have done numerous posts on the 92225 proc code. My main reason for this is because it is highly abused among optometrists and optometric billers and billing staff alike. Therefore, in an effort to continue to provide more clarity on this subject I am publishing a list of acceptable Diagnosis Codes that can be reported to Medicare (and most other insurances) when billing for this procedure. I would like to point out that this list is based on Texas medicare Local Coverage Determinations (LCD's) but it is a good reference point for any state as variations in the rule are minute. If you have any questions about your state, feel free to contact Andrew Roy at 802-253-7201 and we will help you find the EXACT DX codes for your state.

Allowed Reimbursamble Diagnoses Pertaining to 92225

115.02                 Retinitis - Infection by Histoplasma Capsulatum [American histoplasmosis - Darling`s disease]

130.2                   Chorioretinitis Due To Toxoplasmosis

190.5                   Malignant Neoplasm - Retina

190.6                   Malignant Neoplasm - Choroid

224.5                   Benign Neoplasm - Retina  [Retinal Nevus]

224.6                   Benign Neoplasm - Choroid [Choroidal Nevus]

228.03                 Hemangioma of Retina

228.09                 Hemangioma - Other Sites

282.60                 Sickle-cell Disease, Unspecified

282.64                 Sickle-cell/Hb-C Disease With Crisis

282.68                 Other Sickle-cell Disease Without Crisis

360.01                 Endophthalmitis - Acute

360.21                 Progressive High (degenerative) Myopia - Malignant myopia

361.00                 Retinal Detachment - Defect - Unspecified

361.01                 Retinal Detachment - Recent - Partial - One Defect

361.02                 Retinal Detachment - Recent - Partial - Multiple Defect

361.03                 Retinal Detachment - Recent - Partial - Giant Tear

361.04                 Retinal Detachment - Recent - Partial - Dialysis

361.05                 Retinal Detachment - Recent - Total or Sub-total

361.06                 Retinal Detachment - Old - Partial

361.07                 Retinal Detachment - Old - Total or Sub-total

361.10                 Retinoschisis - Unspecified

361.11                 Retinoschisis - Flat

361.12                 Retinoschisis - Bullous

361.13                 Retinal Cysts - Primary

361.14                 Retinal Cysts - Secondary

361.19                 Other Retinoschisis And Retinal Cysts

361.2                   Retinal Detachment Serous - without retinal defect

361.30                 Retinal Defect - Unspecified w/o Detachment

361.31                 Retinal Hole w/o Detachment

361.32                 Retinal Tear w/o Detachment

361.33                 Retina - Multiple Defects w/o Detachment

361.81                 Retinal Detachment - Tractional

362.01                 Background Diabetic Retinopathy

362.02                 Proliferative Diabetic Retinopathy

362.03                 Nonproliferative Diabetic Retinopathy

362.04                 Mild Nonproliferative Diabetic Retinopathy

362.05                 Moderate Nonproliferative Diabetic Retinopathy

362.06                 Severe Nonproliferative Diabetic Retinopathy

362.07                 Diabetic Macular Edema

362.10                 Background Retinopathy - Unspecified

362.12                 Retinopathy - Exudative - Coats` syndrome

362.13                 Changes In Vascular Appearance of Retina - Vascular sheathing of retina

362.14                 Retinal Microaneurysms - NOS

362.15                 Retinal Telangiectasia

362.16                 Retinal Neovascularization - NOS

362.21                 Retrolental Fibroplasia [Cicatricial retinopathy of prematurity]

362.31                 Central Retinal Artery Occlusion

362.32                 Arterial Branch Occlusion

362.35                 Central Retinal Vein Occlusion

362.36                 Venous Tributary (Branch) Occlusion of Retina - BVRO

362.41                 Retinopathy - Central Serous

362.42                 Serous Detachment of Retinal Pigment Epithelium [Exudative detachment]

362.43                 Hemorrhage Detachment of Retinal Pigment Epithelium

362.52                 Macular Degeneration - Exudative Senile (WET) [Kuhnt-Junius degeneration]

362.53                 Macular Degeneration - Cystoid

362.54                 Macular Cyst or Hole or Pseudo-hole of Retina

362.56                 Macular Puckering [Preretinal Fibrosis, Epiretinal membrane]

362.63                 Lattice Degeneration of Retina [Palisade degeneration of retina]

362.74                 Pigmentary Retinal Dystrophy [Retinitis Pigmentosa, Albipunctate]

362.81                 Retinal Hemorrhage

362.83                 Retinal Edema [Cotton Wool Spots, Macular, Peripheral, Localized]

362.84                 Retinal Ischemia

363.00                 Focal Chorioretinitis - Unspecified

363.01                 Focal Choroiditis and Chorioretinitis - Juxtapapillary

363.03                 Focal Choroiditis and Chorioretinitis of Other Posterior Pole

363.04                 Focal Choroiditis and Chorioretinitis - Peripheral

363.05                 Focal Retinitis and Retinochoroiditis - Juxtapapillary [Neuroretinitis]

363.06                 Focal Retinitis and Retinochoroiditis - Macular or Paramacular

363.07                 Focal Retinitis And Retinochoroiditis of other Posterior Pole

363.08                 Focal Retinitis And Retinochoroiditis - Peripheral

363.10                 Disseminated Chorioretinitis - Posterior

363.11                 Disseminated Chorioretinitis - Unspecified

363.12                 Disseminated Chorioretinitis - Peripheral

363.13                 Disseminated Chorioretinitis - Generalized

363.14                 Disseminated Retinitis and Retinochoroiditis - Metastatic

363.15                 Disseminated Retinitis and Retinochoroiditis - Pigment Epitheliopathy [Acute posterior multifocal placoid]

363.20                 Chorioretinitis - Unspecified [Choroiditis NOS, Retinitis NOS, Uveitis posterior NOS]

363.21                 Pars Planitis [Posterior cyclitis]

363.22                 Harada`s Disease

363.30                 Chorioretinal Scar - Unspecified

363.70                 Choroidal Detachment [Commotio Retinae, Choroidal Hemorrhage]

363.71                 Choroidal Detachment - Serous [Commotio Retinae, Choroidal Hemorrhage]

363.72                 Choroidal Detachment - Hemorrhagic [Commotio Retinae, Choroidal Hemorrhage]

365.10                 Open-angle Glaucoma Unspecified [Wide-angle Glaucoma NOS]

365.11                 Primary Open Angle Glaucoma [Chronic, Simple, Noncongestive, Nonobstructive]

365.12                 Low Tension Open-angle Glaucoma

365.13                 Pigmentary Open-angle Glaucoma

365.14                 Glaucoma of Childhood [Infantile, Juvenile Glaucoma]

365.20                 Primary Angle-closure Glaucoma Unspecified

365.21                 Intermittent Angle-closure Glaucoma [Interval, Sub-acute]

365.22                 Acute Angle-closure Glaucoma [Attack, Crisis]

365.23                 Chronic Angle-closure Glaucoma

365.24                 Residual Stage of Angle-closure Glaucoma

365.31                 Corticosteroid-induced Glaucoma Glaucomatous Stage

365.32                 Corticosteroid-induced Glaucoma Residual Stage

365.42                 Glaucoma Associated With Anomalies of Iris [Anomalies NEC, Atrophy, Essential]

365.44                 Glaucoma Associated With Systemic Syndromes

365.62                 Glaucoma Associated With Ocular Inflammations

365.63                 Glaucoma With Vascular Disorders of Eye

365.65                 Glaucoma Associated With Ocular Trauma

368.15                 Other Visual Distortions and Entoptic Phenomena [Refractive: diplopia; polyopia; Photopsia; Visual halos]

379.21                 Vitreous Degeneration [Vitreous cavitation, detachment, liquefaction]

379.23                 Vitreous Hemorrhage

379.24                 Other Vitreous Opacities [Vitreous Floaters, Vitreous Syneresis]

379.26                 Vitreous Prolapse

379.29                 Other Disorders of Vitreous

379.34                 Dislocation - Posterior Lens

871.5                   Penetration of Eyeball with Magnetic Foreign Body

871.6                   Penetration of Eyeball with Nonmagnetic Foreign Body

996.53                 Mechanical Complication Due To Ocular Lens Prosthesis

E931.4                Antimalarials/Drugs Acting On Other Blood Protozoa Causing Adverse Effects In Theraputic Use

V58.69                Long-Term (current) Use of Other Medications Need Help With other Codes or Just want a full time billing department to handle your optometric billing? Click here to contact opticXpress now!

Optometric Billing-92225-Another Word

When looking over optometricmanagement.com this morning, an excerpt from an article caught my eye concerning the 92225 procedure code. According to the article:

"7 DON'T ABUSE EXTENDED OPHTHALMOSCOPY (CPT CODE 92225).

This is the most abused, and audited, procedure code.
Extended ophthalmoscopy is for serious retinal disorders, such as retinal detachment, and requires detailed color drawings with interpretation. Reimbursement for extended ophthalmoscopy has declined sharply and many practitioners prefer to take a photograph for documentation." (http://www.optometricmanagement.com/articleviewer.aspx?articleid=70838)

Here at opticXpress we run the billing department for Stowe Eyecare, in Stowe, VT, which is where we are now located. (If you have never been here...you should visit...trust me) So I went to the data and compared it to what the article said above. Sure enough, reimbursements have declined and my suspicion is because rather than making drawings to support the use of the procedure code, many optometrists are turning to taking photos as it is not only less time consuming and more accurate but makes it much easier to attach it to an Electronic Medical Record.  

Document, Document, Document, Document! That is the key to proper billing...espescially if you are asking your billing department to submit 92225 for you. Don't worry about being audited for using this code if you are taking the time to properly document. 

If you need help with your optometric billing, call opticXpress today! 

Optometric Billing-the 92225 Procedure Code-UPDATED 01/10/2014

*UPDATED 01/10/2014*

Attention Optometrists and Optometric Billers:


When using 92225 you must be making diagrams. The official definition as reported by the AMA is: Ophthalmoscopy, extended, with retinal drawing.

***UPDATED INFO: Enhanced Definition- "Extended ophthalmoscopy is the illuminated and magnified vascular and nerve examination of the fundus.  It includes the optic disk, retinal vessels, macula and retina.  It may be a dilated procedure.  Always includes a detailed drawing of the retina."-EyeCOR by NTeon

This means that unless there is retinal involvement you should not use this code. You MUST also make your drawings and enter them into the patient's file whenever using 92225. This code is heavily abused by the optometric community and such is the reason I am writing about it today.

This code is also not appropriate to use for dilations as there is no official procedure code for a dilation.

I hope this is helpful to all who read.

Please visit our optometric billing website by clicking here. We will be more than happy to speak with you regarding any questions you may have.