While all services are governed by what is reasonable and medically necessary, the number of diagnostic procedures applicable to the retina is extensive and the range of application is very wide.
Common Retina Evaluations
• Fundus photography (92250). Keep in mind the overlying principal with this very common diagnostic procedure: The photograph must be used in the plan of care for the patient. Simply documenting the existence of pathology is not considered medically necessary. Check with your local payor—in some cases, you can take baseline photos of your patients with diabetes, even when no retinal pathology is present.
• Extended ophthalmoscopy (92225/6). Extended ophthalmoscopy is possibly the most under-utilized diagnostic procedure by optometrists, but one of the most scrutinized by carriers for abuse. Unlike fundus photography, this procedure is used to document that everything is normal if the patient presents with specific symptoms.
Know the difference between routine ophthalmoscopy of healthy tissue and extended evaluation and documentation of diseased states. Extended ophthalmoscopy is indicated when you cannot obtain information about the retina by any other means (i.e., a photo). Extended ophthalmoscopy is a unilateral procedure and is billed per eye; check your individual payor for documentation guidelines because a detailed drawing is generally required for medical compliance.
• Visual fields (usually 92083). If the patient has compromised tissue, it’s reasonable for you to determine if the diseased state has any effect on the patient’s function. The diagnostic codes applicable to visual field testing are usually far more extensive than you’ll need for most retinal disease applications.
Occasional Retina Evaluations
• Scanning computerized ophthalmic diagnostic imaging (92135). Scanning lasers have opened up retinal diagnostic capabilities we never comprehended as recent as a decade ago. They are quickly becoming an advisable, if not essential, element of high level retina disease management. This is also a unilateral test, so bill each eye separately.
• Ultrasound imaging: Diagnostic A-scan (76511), B-Scan (76512), A- and B-scan performed together (76510). A-scans have far more applications than IOL calculation. CPT has even differentiated use of A-scans for diagnostic reasons (76511) vs. IOL calculation (76519). A- and B-mode ultrasound can be helpful in determining location, depth and size of retinal and deeper tissue lesions. They are usually billed with a technical component (-TC modifier billed once for both eyes) and an interpretation component (-26 modifier billed for each eye).
• Fluorescein angiography (92230/5). Although the use of scanning lasers has decreased the need for angiographic studies, this is still an important and sometimes essential adjunct in making the correct diagnosis. Oral fluorescein angiography, also a unilateral test, can be very beneficial in analyzing diseases affecting mid- and late-stage circulation. CPT does not differentiate between intravenous and oral applications of this diagnostic test.
• Electrodiagnostic procedures: electroretinogram (92275), visual evoked potential (95930). These diagnostic tests are certainly well within the competency and scope of the optometrist. New instrumentation has also made the clinical application of these tests easier and more affordable. Check with your local payor to make sure optometrists are included in the reimbursement of these procedures (and take steps to include them if they are not!).
In all cases, become familiar with the guidelines established by the Medicare payor for your state and the payment guidelines of the major medical carriers you work with.
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