Transcript 92000 Codes Special Ophthalmological Services

Dr. Harvey Richman, OD, FAAO, FCOVD
Diplomate American Board of Optometry
AOA Third Party Center Executive Committee
“CodeHead”
Disclaimers
Medicare policy changes frequently so links to
the source documents have been provided for
your reference.
2. This presentation is prepared as a tool to assist
providers and is not intended to grant rights or
impose obligations.
3. Every reasonable effort has been made to assure
the accuracy of the information.
4. Ultimate responsibility for the correct
submission of claims and response to any
remittance advice lies with the provider of
services.
1.
Disclaimers
6. This presentation is general summary that explains certain
aspects of the Medicare program, but is not a legal document.
The official Medicare program provisions are contained in the
relevant laws, regulations, and rulings.
7. The Medicare Learning Network (MLN) is the brand name for
official CMS educational products and information for
Medicare fee-for-service providers. For additional information
visit the Medicare Learning Network’s web page at
www.cms.hhs.gov/MLNGenInfo on the CMS website.
8. Current Procedural Terminology (CPT) is copyright by the
American Medical Association. All Rights Reserved. No fee
schedules, basic units, relative values, or related listings are
included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to
government use.
92000 Codes
Special Ophthalmological Services
Describe Services in which a special Evaluation
of part of the visual system is made, which goes
beyond the services, or in which special treatment
is given.
Special ophthalmological services may be reported
in addition to the general ophthalmological services
or evaluation and management services
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92000 Series Codes
 Extended Ophthalmoscopy*
 Not a Routine BIO
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Angiography (Fluorescein / Indocyanine Green)
Fundus Photography*
Scanning Laser Technology*
Color Vision Examination
Gonioscopy
External Ocular Photography*
Sensorimotor Evaluation
Visual Fields*
Effect of Lenses
With Lenses
Without Lenses
Refraction-92015
 Determination of refractive state
 Statutorily not covered by Medicare
 RVU $38.09
 Consider Modifiers
Refraction 92015
 By CMS Statute a Non-Covered Service
 Patient Responsibility
 ABN Not Required but Useful
 GY Modifier
 Multilevel Refraction Codes 92015?
 Phoropter
 Trial Frame
 Telescope
Modifiers
 21-Prolonged E&M Services
 When the face to face service is prolonged or otherwise
greater than that usually required for the highest E & M
service within a given category. A report may be
appropriate.
 22- Increased Procedural Services
 When the work required to provide a service is
substantially greater than what is typically required.
Documentation must support the substantial additional
work and the reason for the additional work. (Time,
difficulty of procedure, severity of patient condition)
 Not to be used with E & M
Gonioscopy
 92020
 Gonioscopic exam to diagnose injury or disease in the
anterior chamber of the eye, performed under local
anesthetic due to necessity of placing specialized lens
directly on the eye to obtain a clear image
 Bilateral Procedure Code
 LCD Utilization
Topography
 92025
 Computerized corneal topography, unilateral or bilateral
with interpretation and report
 Detection of subtle corneal surface irregularity and
astigmatism
 Report one time only
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Indications & Limitations of
Coverage:
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Post penetrating keratoplasty
Post kerato-refractive complications
Post op irregular astigmatism
Corneal dystrophy, bullous keratopathy
Complications of transplanted cornea,
Keratoconus
Reasons For Denial:
 Non-covered for refractive procedures
 Often billable privately for contact lens
evaluations or included in examination fee
Sensorimotor Exam
 92060
 Sensorimotor examination (i.e. of the movement of
the eye), conducted by taking measurements as the
eyes focus on different locations or through one or
more prisms. Searches for deviations in normal eye
movements, which may result from injury or
disease. Includes interpretation and report.
92071
 Fitting of a contact lens for treatment of ocular surface
disease
 Report materials in addition to this code, using either
99070 or the appropriate HCPCS Level II material
code.
 This is the appropriate code to use for fitting a bandage
contact lens.
92072
 Fitting of a contact lens for management of
keratoconus, initial fitting.
 For subsequent fittings, please use either the 9921X or
9201X codes.
 Report materials in addition to this code, using either
99070 or the appropriate HCPCS Level II material
code.
Visual Field Examinations
 92081
Limited, unilateral or bilateral,with
interpretation and report; examination
 92082
Intermediate, unilateral or bilateral,
with interpretation and report
 92083
Extended, unilateral or bilateral, with
interpretation and report
Indications & Limitations of
Coverage
 Necessary to establish
a diagnosis
 Monitor a course for
treatment
 Determine if a change in
therapeutic plan
Indications & Limitations of
Coverage
 92081-92082 medically necessary to
diagnose and follow retinal disorders
 92083 diagnosis or follow-up of
glaucoma
Coding Guidelines
 All services are considered bilateral
 -50 modifier is not appropriate
 -52 modifier if only doing one eye
Blepharoplasty Guidelines
 Visual field examinations to determine the need
for blepharoplasty are sometimes performed
twice, once with the eye(s) taped and immediately
repeated without the eye(s) taped. In this
situation, the repeated service should be
submitted with CPT modifier 76 on a separate
detail line.
Serial Tonometry
92100 (Separate Procedure)
With multiple measurements of intraocular pressure over an
extended time period with interpretation and report, same
day (eg, diurnal curve or medical treatment of acute
elevation of intraocular pressure)
 Bilateral Code
 Modifier if appropriate
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Scanning Laser Tests
 Confocal laser scanning ophthalmoscopy
(topography)
 Optical Coherence tomography
Coding guidelines
 92132-3-4 Scanning computerized ophthalmic
diagnostic imaging (e.g., scanning laser) with
interpretation and report, unilateral
 Using either a 52- LT or RT modifier if reduced
 CPT codes not covered with SLT:
 92225, 92226, 76512, 92250
 59 modifier usage
 GA modifier usage with ABN
92132-SCANNING COMPUTERIZED OPHTHALMIC
DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH
INTERPRETATION AND REPORT, UNILATERAL OR
BILATERAL
 Narrow angle, suspected narrow angle, and mixed
narrow and open angle glaucoma
 Determining the proper intraocular lens for a patient
who has had prior refractive surgery and now requires
cataract extraction
 Iris tumor
 Presence of corneal edema or opacity that precludes
visualization or study of the anterior chamber
92132-SCANNING COMPUTERIZED OPHTHALMIC
DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH
INTERPRETATION AND REPORT, UNILATERAL OR
BILATERAL
 Calculation of lens power for cataract patients who
have undergone prior refractive surgery. Payment will
only be made for the cataract codes as long as
additional documentation is available in the patient
record of their prior refractive procedure. Payment will
not be made in addition to A-scan or IOL master.
 Certain exceptions that must be determined on a caseby-case basis with the appropriate documentation.
92133Glaucoma Indications
 SCANNING COMPUTERIZED OPHTHALMIC
DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH
INTERPRETATION AND REPORT, UNILATERAL OR
BILATERAL; OPTIC NERVE
 Technological improvements have rendered SCODI as a
valuable diagnostic tool in the diagnosis and treatment of
glaucoma. These improvements enable discernment of
changes of the nerve fiber even in advanced cases of
glaucoma.
 It is expected that only two exams/eye/year would be
required to manage the patient who has glaucoma or is
suspected of having glaucoma.
MILD visual field abnormality (inner circle =
10 degrees, outer circle = 20 degrees)
ICD 9 365.71
MODERATE visual field abnormality (inner
circle = 10 degrees, outer circle = 20 degrees)
ICD 9 365.72
SEVERE visual field abnormality (inner circle = 10
degrees, outer circle = 20 degrees)
ICD9 365.73
Glaucoma Severity/Staging Level
Scanning Laser Frequency
 The current frequency limitations for Scanning Laser for
most regions are:
 Mild or Suspect Glaucoma
 Moderate Glaucoma
 Advanced or Severe Glaucoma
1 Time per year
2 Times per year
NO Scanning laser. Up to
4 Visual Fields per year
Utilization Guidelines-GLC
 Although CMS guidelines state
 Only two exams/eye/year are allowed for the patient
who has or is suspected of having glaucoma
 Most LCD state once per year to follow pre-glaucoma
patients or those with “mild” damage
 One or two tests per year for patients with “moderate
damage,”
 followed with SLT or visual fields
 if both SLT and visual fields are used, only one of each
tests
 “Advanced damage,” field testing preferred by
Medicare guidance
92134-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC
IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND
REPORT, UNILATERAL OR BILATERAL; RETINA
 Retinal disorders are the most common causes of
severe and permanent vision loss. These technologies
are valuable tools for the evaluation and treatment of
patients with retinal disease, especially macular
abnormalities.
 These imaging techniques are useful tools to measure
the effectiveness of therapy, and in determining the
need for ongoing therapy, or the safety of cessation of
therapy.
92134-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC
IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND
REPORT, UNILATERAL OR BILATERAL; RETINA
 It is expected that only one exam/eye/2 months would be
required to manage the patient whose primary
ophthalmological condition is related to a retinal
disease. However, for those patients who are undergoing
active treatment for macular degeneration or diabetic
retinopathy one exam/eye/month may be appropriate for
the management of their disease.
 The use of fluorescein angiography, indocyanine green
angiography and SCODI to study the patient’s same eye per
clinical encounter will NOT be authorized. However,
SCODI and fluorescein angiography may be obtained on
the patient’s same eye per clinical encounter if the medical
record substantiates the need for both studies.
Utilization Guidelines-AMD/DR
 Only one exam/eye/2 months is allowed for the patient
whose primary ophthalmological diagnosis is related
to a retinal disease
 One exam/eye/month is allowed for the patient who is
undergoing active treatment for macular degeneration
or diabetic retinopathy
Extended Ophthalmoloscopy
 92225 - Ophthalmoscopy, extended, retinal
drawing with interpretation & report; initial
 92226 - ... Subsequent
Extended Ophthalmoscopy
 Reserved for the meticulous evaluation of a
severe ophthalmologic problem
 Always include indirect ophthalmoscopy & one
other method viewing detail
 Retinal drawing with detail a must.
Coding Guidelines:
 unilateral procedure
 Do not report codes with modifier –50
 Service on both eyes, use LT or RT (uncommon)
LCD Guidelines
 Extended ophthalmoscopy is covered when
prolonged time is required for a detailed
examination of possible retinal lesions or followup of lesions under treatment or surveillance.
92225-92226 LCD
 The patient's medical record must document the medical necessity of
services performed for each date of service submitted on a claim, and
documentation must be available to Medicare on request.

For consideration of CPT codes 92225-92226 (extended
ophthalmoscopy with retinal drawing), retinal pathology must be
present to justify detailed examination. The retinal drawing should be
labeled and include major landmarks, lesions and surrounding
pathology. As an example, a drawing should provide sufficient detail as
to the extent of a retinal detachment or the location of retinal holes in
relation to major structures. Areas of traction, vitreous opacities,
hemorrhage, etc. should be drawn and labeled to facilitate follow-up,
referral to another physician, or purposed surgical treatment of the
patient. A brief verbal interpretation of the findings is also required.
Documentation Guidelines???
 Drawing has to be a certain size (no)
 Observation with two or more lenses (maybe)
 Scleral Indentation must be done
 Colored Drawings with colored pencils (match
international recommendations).
 Must have interpretation and report as well as orders!
Documentation Requirements:
 Reason for performing the examination
 Technique used
 Drawing of the retina showing anatomy seen
including the pathology
 Legible narrative report of the findings
 Documentation supporting medical necessity must
be submitted
92250:Fundus Photography
Fundus photography with interpretation and report
 Bilateral Code
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Photography
 Document abnormalities
 Check carrier’s medical policy for limitations or
restrictions of coverage
 Obtain filing requirements from carrier for
bilateral or multiple procedures
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92250 Utilization Guidelines
 Fundus photography. Generally, it is not medically
necessary to repeat fundus photography more
often than every 2 years for follow-up of stable
glaucoma. Repeat photographs for retinopathy are
rarely necessary.
92275-ERG
 Electroretinography with interpretation and report
 Bilateral Code
 No LCD-YET
 Most TPP experimental except for plaquenil
 Not for EOMs
Anterior Segment Photography
92285
 External ocular photography with interpretation and report
for documentation of medical progress (eg, close-up
photography, slit lamp photography, gonio-photography,
stereo-photography)
 Medicare Fees National Non-Facility Fee $43.58
External Ocular Photography
92285
 Bilateral Code
 Check carrier for limitations or restrictions of
coverage
 NCCI
 92020, 99211, 15820, 15821, 15822, 15823
 Modifier indicator of “1” on 92020, 99211, 15820, 15821,
15822, 15823
 append appropriate modifier if rendered together
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LCD Definition
 External ocular photography is covered when a special
camera is used to obtain magnified photographs of
lesions (e.g., the cornea, iris or lids) for the purpose
of following the patient's condition. Medical quality
images may be of digital, Polaroid Macro 3 SLR or
equivalent. Simple Polaroid photographs for the
purpose of documenting for medicolegal purposes or
preauthorization (e.g., gross trauma, amount of ptosis
or redundant lid tissue) are not separately
reimbursable since they are not medically necessary.
92310
Prescription of optical and physical characteristics of
and fitting of contact lens, with medical supervision
of adaptation; corneal lens, both eyes, except for
aphakia:
 Fitting of one eye, append -52 modifier
 Non Covered Service for Medicare
 Non-Facility Fee $91.81
 HCPCS: V codes
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92311-92313
Prescription of optical and physical characteristics of
and fitting of contact lens, with medical supervision
of adaptation; corneal lens for aphakia, …..
99311-one eye
99312-two eyes
99313-corneoscleral lens
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92314
Prescription of optical and physical characteristics of
and fitting of contact lens, with medical supervision
of adaptation and direction of fitting by independent
technician; corneal lens, both eyes, except for
aphakia:
 Fitting of one eye, append -52 modifier
 Non Covered Service for Medicare
 Non-Facility Fee $72.64
HCPCS: Vcodes
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92315-92317
Prescription of optical and physical characteristics of
and fitting of contact lens, with medical supervision
of adaptation and direction of fitting by independent
technician; corneal lens for aphakia, …..
92315-one eye
92316-two eyes
92317-corneoscleral lens
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Contact Lens Evaluations
 92325
 Modification of contact lens (separate procedure),
with medical supervision of adaptation
 Lay description-Modification of contact lens,
typically by grinder or polisher, to provide a better
fit
 Non-Facility Fee $29.13
Contact Lens Evaluations
 92326
 Replacement of contact lens under current prescription
(due to damage, loss, etc.).
 Non-Facility Fee $34.66
95930
 Visual Evoked Potential
 Visual Evoked Potential testing central nervous system,
checkerboard or flash
 Bilateral Code
 General Supervision
 Special Training?
 No Utilization Guidelines YET
60000 series codes
 Surgery - Eye and Ocular Adnexa
 Global surgical periods apply to all surgical
procedures.
CPT Surgical Package
 The CPT codes that represent a readily identifiable
surgical procedure thereby include, on a
procedure-by-procedure basis, a variety of
services. In defining the specific services
"included" in a given CPT surgical code, the
following services are always included in addition
to the operation per se:
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Co-Management of
Surgical Procedures
Management of a surgical procedure is the
primary responsibility of the operating Surgeon.
Physicians who perform surgery, and furnish all
the usual pre and post-operative work should
bill for global surgery using the proper CPT
Surgical code (s) after appending the
appropriate modifier to the surgical CPT code.
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Co-Management of
Surgical Procedures
 Transfer of global surgery must be
Clinically necessary and appropriate.
 The Transfer of care is allowed only to protect the
interest of the patient.
 The physician receiving the patient must be
licensed to manage all aspects of the postoperative
care, including diagnosing potential complications
that would require a return to surgery.
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Co-Management of
Surgical Procedures
 Co-management is indicated under any of the
following circumstances:**
 When the surgeon is unavailable after surgery and
the patient’s post-operative care has to be managed
by another physician
 When the patient is unable to travel the distance to
get to the surgeon for F/U care.
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Co-Management of
Surgical Procedures
 When the patient elects to have F/U care provided
by another provider
 When the surgeon practices in a site remote from
where the patient recuperates
 A second illness has developed which prevents
travel to the operating surgeon
 Surgery is performed while the patient is traveling,
vacationing or living in a distant location
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Foreign Body Removal
 65205: Conjunctival FB Removal,
superficial
 65210: Conjunctival FB Removal,
embedded
 65220: Corneal FB Removal w/o Slit
Lamp
 65222: Corneal FB Removal w/ Slit
Lamp
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Multiple Foreign Body Removal
 ICD.10 CM Diagnosis Codes
 S05.01XA Injury of conjunctiva and corneal abrasion without foreign body,
right eye, initial encounter (note: include cause)
 S05.01XD Injury of conjunctiva and corneal abrasion without foreign body,
right eye, subsequent encounter (note: include cause)
 S05.02XA Injury of conjunctiva and corneal abrasion without foreign body, left
eye, initial encounter (note: include cause)
 S05.02XD Injury of conjunctiva and corneal abrasion without foreign body, left
eye, subsequent encounter (note: include cause)
Use modifier 22 for multiple foreign body removals requiring extended
period of time
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Removal of Corneal Epithelium
 65435
 Removal of corneal epithelium; with or without
chemocauterization
Epilation of Trichiasis
 67820 When the eyelashes are
ingrown or misdirected
(trichiasis), the
physician uses a
biomicroscope and
forceps to remove the
offending eyelashes.
Punctal Dilation
 68801
 Dilation of lacrimal punctum, with or
without irrigation
 It's best not to perform the dilation on the
same day as insertion. Don't include the
procedure as a routine component of code
68761
 Bilateral use with modifier 50
 Medicare Fees National Non-Facility Fee
$106.87
Punctal Probing
 68810
 Probing of nasolacrimal duct, with or without
irrigation
 Medicare Fees National Non-Facility Fee $230.80
Punctal Occlusion
 68761
 Closure of the lacrimal punctum; by plug,
each
 10 Day Post Op period
 Medicare Fees National Non-Facility Fee $131.50
Punctal Occlusion Reporting
 100% First Puncta
 50% Second Puncta
 25% Third and Fourth Puncta
 Modifiers Needed for Multiple Plugs
 E1-E4
 50
 51
 99
ICD-X-CM Diagnosis Codes
 Superficial keratitis, unspecified
 Punctate keratitis, Thygeson’s superficial punctate keratitis
 Keratoconjunctivitis sicca, not specified as Sjögren’s
 Exposure keratoconjunctivitis
 Conjunctival xerosis
 Tear film insufficiency, unspecified dry eye syndrome
 Stenosis of lacrimal punctum
 Stenosis of nasolacrimal duct, acquired
 3Pain in or around the eye
 Redness or discharge
 Sicca syndrome (keratoconjunctivitis sicca, Sjögren’s disease)
Punctal Plug Supply
 A4262
 TEMPORARY, ABSORBABLE LACRIMAL DUCT
IMPLANT, EACH
 Medicare Fees National Non-Facility Fee $0.00
 Status B (bundled)
Punctal Plug Supply
 A4263
 PERMANENT, LONG TERM, NON-DISSOLVABLE
LACRIMAL DUCT IMPLANT, EACH
 Medicare Fees National Non-Facility Fee $0.00 (B)
Punctal Plug Supply ?
 99070
 Supplies and materials (except spectacles), provided
by the physician over and above those usually included
with the office visit or other services rendered (list
drugs, trays, supplies, or materials provided)
 Medicare Fees National Non-Facility Fee $0.00
Diagnostic CPT's
Pachymetry:
CPT 76514
 Bilateral.
 Billable for Corneal
Problems and
Glaucoma.
 Requires
Interpretation
and Report.
Laboratory Testing
80000 Series Codes
 Pathology and Laboratory Testing
 Must be CLIA certified facility
 Line 23 on HCFA
Tear Assay
 83516
Immunoassay for analyte other than infectious agent
antibody, quantitative or semi-quantitative
Used to analyse tear composition for Lactoferrin
CLIA certification is required
Tear Assay
 Bilateral code
 Paid one time for both eyes
 Clinical Lab Fees
2016 Clinical Diagnostic Laboratory (National
Limit): $16.12
Adenovirus Testing
 87809
 Infectious agent antigen detection by immunoassay with
direct optical observation; adenovirus
 Rapid Pathogen Screening
 Bilateral code-Paid one time for both eyes
 Clinical Lab Fees-2016 Clinical Diagnostic Laboratory
(National Limit): $16.76
 CLIA certification is required
Thanks for your time, now……