Optometric practice calls for just a handful of commonly
used codes for the retina:
• 92081 to 92083 (Visual field examination, unilateral or
bilateral). CPT codes 92081, 92082 and 92083 are used for visual field testing
listed in increasing sensitivity; 92083 is usually used for full threshold
tests (i.e., 30-2). CPT defines this test as unilateral or bilateral, and it
should be reported the same way whether it is performed on one or both eyes:
Always report the units as 1, with no price adjustment for unilateral or
bilateral. An interpretation and report of the data must also be included.
• 92135 (Scanning computerized ophthalmic diagnostic imaging
[SCODI] with interpretation and report, unilateral). SCODI is a unilateral
test, so if you perform the procedure on both eyes, you must report that you
performed the test twice by one of two methods: You may use modifier -50 and
report it on a single line and units of 2 while doubling your fee, or you can
use the modifiers RT and LT to designate right and left eye.
I prefer using the RT and LT modifiers for several reasons.
One, it’s easy to make two different codes in your billing software and just
mark them both on your routing slip, which creates two line items on your
claim. That way, you’re sure to get paid correctly for both eyes. Second, by
using RT and LT, anyone in your office—front desk receptionist, optometric
assistant or insurance specialist—knows exactly what procedure you did, which
eye(s) you evaluated, and exactly what procedure(s) you’re billing for.
• 92250 (Fundus photography with interpretation and report).
Fundus photography is used to compare and track changes in the retina. It can
assist you with treatment and management decisions. Fundus photography is
usually not covered for documenting the existence of a condition, but is used
as a baseline and to monitor change or to confirm stability. The frequency of
subsequent fundus photographs should be determined by “medical necessity” and
clearly documented in the medical record.
In most areas
of the country, third-party payers don’t cover routine (screening) fundus
photography because they don’t consider screening photos to be medically
necessary. Screening photos should not be assigned CPT code 92250, but should
be associated with the Healthcare Common Procedure Coding System (HCPCS) level
II code S9986, which is defined as “Not medically necessary service.”
Also, be aware that simply finding pathology on a screening
photo does not make that screening photo a “medical photo” that is billable to
a carrier. Simply put: Once a screening photo, always a screening photo. Upon
further physical examination of the patient, if another photo is medically
necessary, then it should be performed and appropriately noted in the medical
92250 is a bilateral code; you don’t need a -50 modifier or
the RT and LT modifiers. However, in many areas in the country, if this test is
performed on only one eye, you may have to indicate it with the RT or LT
modifier and reduce your fee. Refer to your specific carrier guidelines for
further detail on the prevailing rule applicable to your practice.
A couple of other points: 92250 (Fundus photography,
bilateral) and 92135 (Scanning laser, unilateral) are considered mutually
exclusive under the National Correct Coding Initiative (NCCI), so don’t bill
for these for the same patient on the same day. Additionally, these special
ophthalmological tests require an interpretation and report in the medical
record. Many carriers are now recouping the entire code reimbursement if the
interpretation and report is absent in the medical record.
• 92225 (Extended ophthalmoscopy, initial), 92226 (Extended
ophthalmoscopy, subsequent). We’ll cover these complex codes in detail in a
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