The retina has traditionally been the domain of ophthalmology and not a typical area for optometrists. Over the past decade, that has changed with the advent of technologies that have since improved in clinical application. In January 2021, the redefinition of the CPT language associated with E&M services dictated the practitioner only perform “a medically appropriate history and examination.” There is now no requirement to dilate to meet the definition of a 992XX code, and because of that, it may change how you decide to employ various technologies into your clinical regimen. Let’s explore some of these technologies and their code requirements.
Fundus Photography (92250)
If medical necessity for bilateral use is not established in the record, it should be performed unilaterally and coded (92250-52-RT/LT). Photo documentation requires that the need for the image be determined on the day of service and after you examined the patient. It generally is not ordered in advance of the examination. Like the five following technologies, it requires an interpretation and report that demonstrates how it added to the care and management of the patient rather than just act as a confirmatory test.
Fundus autofluorescence is also coded as 92250 and follows the same rules for use and medical necessity. Watch out for performing 92250 on the same day of service as any of these other common ophthalmic codes: 92201, 92202, 99211, 92227, 92228, 92229, 92133, 92134, 92235, 92240.
OCT (92133 for Optic Nerve, -34 for Retina)
Described as a “unilateral or bilateral” procedure, OCT is coded and paid the same whether it is performed on one eye or both. 92133 and 92134 cannot under any circumstances be performed on the same date of service according to the CCI edit rules. OCT and OCT angiography are coded in the same manner and follow the same guidelines.
In order to use OCT to follow a Plaquenil (hydroxychloroquine, Sanofi) patient, you must be using spectral domain–level equipment or better. Watch out for performing 92133 or 92134 on the same day of service as any of these other common ophthalmic codes: 76513 99211, 92227, 92228, 92229, 92250.
Dark Adaptation (92284)
Using this technology for early detection of macular degeneration has become more user-friendly. CPT 92284 is considered, per AMA/CPT and CMS guidelines, to be an inherently unilateral/bilateral code that can be reported once per session when performed in one eye or both eyes, without the use of code modifiers for laterality. Like all special testing, medical necessity is required when performing the test based upon clinical findings.
In general, 92284 can be performed on the same day of service as most other ophthalmic tests but has a CCI edit rule that prevents it from being performed on the same day as 99211.
Extended Ophthalmoscopy (92201, -02)
Described as a “unilateral or bilateral” procedure, this is coded and paid the same whether it is performed on one eye or both. Redefined in January 2020, these codes now reflect examination of specific areas of the retina with specific examination techniques. Watch out for a Correct Coding Initiative (CCI) edit preventing you from performing either code on the same day as fundus photography.
Visual Fields (92081, -82, -83)
Described as a “unilateral or bilateral” procedure, visual fields are coded and paid the same whether performed on one eye or both. Make sure that the level of visual fields performed matches the level of medical necessity established in the medical record. In general, visual fields can be performed on the same day of service as most other ophthalmic tests but have a CCI edit rule preventing them from being performed on the same day as 99211.
Electroretinogram (92273, -74)
In January 2019, 92275 was supplanted by these two CPT codes specifying specific examination techniques. These tests are true bilateral tests. Electroretinography can be performed on the same day of service as most other ophthalmic tests but has a CCI edit rule that prevents it from being performed on the same day as 99211.
The retina is fertile territory for optometric specialization. Using technology to boost your clinical acumen and knowing the coding rules surrounding this technology will benefit your patients and boost your practice.
Send your coding questions to firstname.lastname@example.org.
Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.