It a new year and that means there are changes with the Current Procedural Terminology (CPT) codes that govern how ODs describe what we do during the physician-patient encounter. Not to mention the tests and procedures we perform on patients. Last month marked the change of one of the most frequently used CPT codes in the ophthalmic space—extended ophthalmoscopy.
Traditionally extended ophthalmoscopy has been a unilateral test described by CPT codes 92225 and 92226. The CPT1 had defined these codes as follows:
• 92225: 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
The preamble for performing extended ophthalmoscopy remains essentially the same. This procedure should be done only when other, less extensive procedures have failed to provide the clinical information necessary to appropriately diagnose, treat, or manage the clinical condition. Simply put, if traditional ophthalmoscopy (direct or indirect) or taking a fundus photograph of the retina provided the necessary information to diagnose, treat, or manage the clinical condition of the patient, then performing extended ophthalmoscopy would not be medically necessary.
Unfortunately, that is not how the code has traditionally been utilized. In my experience, many clinicians performed the procedure without establishing appropriate medical necessity. This is due, in part, to the fact that it is a unilateral test, billed per eye, which provides solid reimbursement when performed on both eyes. Additionally, the definition of the codes (as described above) was fairly general with the only differentiation between the codes being the words “initial” and “subsequent”. Both codes did require an actual drawing of the area of concern within the retina and an interpretation and report in order to fulfill the CPT requirements.
CPT Professional Edition, American Medical Association, 2019, pg.650
CPT Professional Edition, American Medical Association, 2020, pg 658