The retina hasn’t traditionally been an area that the average OD has been actively involved in managing. But things have changed. Now, ODs can not only diagnose retinal disease, such as AMD, but also actively manage retinal conditions.
Therefore, keep these points in mind when coding for retinal examinations and/or special ophthalmic procedures related to the retina:

1. According to the CPT, dilation is not mandatory when performing any 920XX code, but is required “as indicated.”^₁

2. When the retinal components of a single system eye examination are performed using a 992XX code, it must be done through a dilated pupil—unless contraindicated because of age or medical reasons.^₂

3. A statement of medical necessity for any return visits to your practice or for any special ophthalmic procedures ordered should be clearly stated in your assessment and plan for the office visit performed that day.

4. A special ophthalmic test that has a specific definition as a separate and distinct procedure (by virtue of having its own CPT code) is not part of any office visit, whether a 920XX or 992XX code.1 This also means that special ophthalmic tests can be ordered and performed by the physician on the same date of service as the office visit, as long as the tests are performed in accordance with the National Correct Coding Initiative Edits and meet all requirements specific to your geographic location for medical necessity.^₁

5. All special ophthalmic tests require an interpretation and report (I&R) that is distinct and separate from any notes contained in the office visit itself (if performed). A special ophthalmic test is not deemed to be complete (or billable) until the physician has completed the I&R.

6. When performing a special ophthalmic test, you’re essentially referring a patient to yourself, and therefore you need to place the name and NPI of the referring physician (even if it’s yourself) into box 17 of the CMS-1500 form to allow the carrier to properly process it, and to avoid a claim rejection.^₃

 7. All special ophthalmic tests are subject to the Multiple Procedure Payment Reduction (MPPR) that was rolled out in 2013. This essentially comes into play when you are performing multiple special ophthalmic procedures on the same day that full payment is made for the technical component (TC) service with the highest payment under the Medicare Physician Fee Schedule. Payment is made at 80% for subsequent TC services provided by the same physician (or by multiple physicians in the same group practice, [i.e., under the same group NPI]) to the same patient on the same day.^₄

Optometry provides the lion’s share of primary eye care in the United States today, so we have not only the obligation to properly diagnose retinal conditions, but also the growing opportunity to provide preventive treatment of retinal conditions that we commonly encounter.


‘Coding & Billing’ Come Second
Keep in mind this very important principle: We don’t perform coding and billing; we provide clinical care, and our clinical medical record is our written proof of the care we provided. The CPT code that is created for an encounter or procedure is nothing more than the legally required translation of the medical care delivered into a five-character code. Likewise, profitability is nothing more than a byproduct of the standard of care, a thorough and accurate medical record, and the translation of the clinical care provided into a CPT code used in accordance with the law we have to follow.

Please send your questions and comments to [email protected].

1. CPT 2014 Professional Edition. Chicago, IL: American Medical Association. 2013: 536.
2. Medicare Learning Network. Evaluation and Management Services Guide. Baltimore, MD: Centers For Medicare and Medicaid Services. 2010: 62.
3. Washington Publishing Company. Claim Adjustment Reason Codes. Updated April 23, 2014. Available at: www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes. Accessed May 20, 2014.
4. MLN Matters. Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures. November 6, 2012. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7848.pdf. Accessed May 20, 2014.