By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
Effective Jan. 1, 2020, two ophthalmoscopy CPT codes became replaced with new codes. Here’s what has changed.
Deleted: 92225 and 92226
The deleted codes were for initial (92225) and subsequent (92226) extended ophthalmoscopy, with “extended” indicating that the clinician had gone beyond a routine exam of the retina and had performed a more extensive examination of the periphery for specific conditions. For both codes, the allowable was per eye, but you couldn’t bill for an eye that didn’t have pathology.
In 2017, the two codes were flagged as being potentially misvalued, and it was also noted that they didn’t adequately indicate what portion of the retina was being examined.
Meet Codes 92201 and 92202
The two replacement codes are defined as follows:
92201 Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral
92202 with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.
Note: Examples of labeled drawings are included in 2020 CPT Professional Edition (aao.org/store).
Payment is inherently bilateral. Unlike the old codes, payment is the same whether one or both eyes has pathology.
Allowables. The allowables vary, depending on where you practice—but regardless of your location, you will be paid less for the new codes than you were for the old ones. Using Baltimore as an example, in 2019, Medicare’s payment for CPT codes 92225 and 92226 was $29.87 and $27.63 per eye, respectively. By contrast, in the same city, CPT code 92201 has an allowable of $27.21 for both eyes, and CPT code 92202’s bilateral allowable is $17.21.
Modifiers. There is no need to append modifiers –RT, –LT, –50, or –52. Submit either 92201 or 92202 without a modifier.
Covered diagnoses. Which diagnosis codes (ICD-10 codes) will support the use of the two new codes? This can vary by payer, so you should check your payer’s policy—but it is likely to be similar, if not the same, as the list of diagnosis codes that were covered for the two retired codes.
Payer policies. Once payers update their policies for the new codes, they will publish local coverage determinations (LCDs) on their websites and the American Academy of Ophthalmic Executives (AAOE) will post them at aao.org/lcds. (At time of press, payers had not updated their policies.)
CCI Edits for the New Codes
CMS publishes pairs of codes, known as Correct Coding Initiative (CCI) edits, that should not be billed together. Some CCI edits are known as “mutually exclusive edits,” meaning they can never be billed together. Other CCI edits can be billed together—in a process known as “unbundling”—if certain criteria are met.
Look for the “0” or “1” indicator. CMS materials use a “0” to flag mutually exclusive edits and a “1” to indicate that a pair of codes can be unbundled.
Mutually exclusive edits. These pairs should never be billed together: 92201 and 92202; 92201 and 92250 Fundus photography; or 92202 and 92250.
E&M code 99211 can be unbundled.CPT code 99211—which is the E&M code for an established patient, level 1—is bundled with each of the new codes, but both of those CCI edits can be unbundled if both services are medically necessary.
Retina procedures can be unbundled. All retina procedures—both minor and major—are bundled with the new codes with an indicator of 1. This means that they can be unbundled if justified by medical necessity. For example, the patient might need extended ophthalmoscopy in one eye and surgery in the other. The codes for these procedures are as follows: 0465T, 67005, 67010, 67015, 67025, 67027, 67028, 67030, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67115, 67120, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67225, 67227, 67228, and 67229.