The new year is nearly upon us, and with it comes changes in many CPT procedures, codes and definitions. One of the most noteworthy is the change with extended ophthalmoscopy. 

The Definition 

Extended ophthalmoscopy is a dilated assessment of the posterior segment using indirect ophthalmoscopy or slit lamp biomicroscopy and an additional diagnostic tool, such as a 3-mirror lens, 20-diopter lens, 90-diopter lens or scleral depression, and includes a detailed drawing of the retina. This provides a high-intensity illumination and a stereoscopic, wide-field view of the fundus for detection and/or evaluation of vitreoretinal pathology.¹ Extended ophthalmoscopy codes are generally reserved for the meticulous evaluation of the eye and with detailed documentation of a severe ophthalmologic problem needing continued follow-up that cannot be sufficiently evaluated with photos.

Codes of the Past 

Historically, extended ophthalmoscopy was defined by two CPT codes:

• 92225: Ophthalmoscopy, extended, with retinal drawing (e.g., retinal detachment, melanoma), with interpretation and report (I&R); initial.
• 92226: Ophthalmoscopy, extended, with retinal drawing (e.g., retinal detachment, melanoma), with I&R; subsequent.

Both codes are unilateral in nature, and medical necessity for each eye must be clearly established in the record. The codes also required a specifically sized drawing, traditionally with “colored pencils,” to denote various anatomical structures and markers and must include an I&R to be a completed test.

According to CMS statistics, these two procedures rank in the top five retinal diagnostic procedures, thus flagging them for the potential for significant waste and abuse.² Documentation for the codes generally required:

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

Documentation in the medical record for a diagnosis of glaucoma must include a detailed drawing of the optic nerve and documentation of cupping, disc rim, pallor, slope and any pathology surrounding the optic nerve.

New Codes and Definitions

Starting in January 2020, extended ophthalmoscopy will be described by two new codes that now include the region of the retina examined and a unilateral/bilateral status:³

• 92201: Ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (e.g., retinal tear, retinal detachment, retinal tumor) with I&R, unilateral or bilateral.
• 92202: Ophthalmoscopy, extended, with drawing of optic nerve or macula (e.g., glaucoma, macular pathology, tumor) with I&R, unilateral or bilateral.

Note that 92201 requires the use of scleral depression, whereas the older codes did not specify any one technique. The new codes still require detailed drawings of the areas of exam and concern. 

The CPT continues to refine definitions of various procedures to ensure physicians have the tools to properly translate the medically necessary services they provide to patients, work in alignment with the ICD-10 and prevent opportunities for waste and abuse. Keeping up to date with these changes in your practice allows you to provide the care your patients require and keeps your practice safe from audit.

Send your coding questions to [email protected].