It’s a new year! Beginning Jan. 1, 2020 YOs have a number of new code updates and changes to learn. Along with reviewing these updates, it’s also a good time to make your staff aware of how this will affect daily billing.
Extended ophthalmoscopy codes 92225 and 92226 were deleted Dec. 31, 2019. These highly utilized codes were up for review, and the Centers for Medicare & Medicaid Services determined they differed only in initial and subsequent language of the codes. Both involved the same physician work, with differences between posterior pole and peripheral exam work. So two new codes were created to better determine what testing is performed.
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: There is currently no code for drawing/documenting peripheral retinal disease without scleral depression.
How do these new codes impact your practice?
Payment — The previous extended and subsequent ophthalmoscopy codes were unilateral, meaning each eye may be submitted when pathology was drawn. The codes 92201 and 92202 are inherently bilateral, meaning that payment is the same whether one or both eyes are examined. Pathology still needs to be drawn and labeled. Modifiers like -RT, -LT or -50 will no longer be required.
Documentation — Scleral depression is expected to be drawn. If contraindicated, be sure to indicate on the drawing. If you don’t, the payer may deny the service.
Bundling — 92201 and 92202 can be unbundled from retinal procedures using a -59 modifier but this is not possible with 99250 (fundus photography with interpretation and report). 92201 and 92202 are also mutually exclusive on the same visit. Practices should also be aware that 92201 and 92202 CAN be unbundled with a -59 modifier. Of course, use of any modifier should be warranted and documentation should support its use.
When would it be appropriate to unbundle? When the EO is performed in the opposite eye than the procedures.
Codes for Surgeries
After reviewing CPT code 66711 Endoscopic cyclophotocoagulation, officials determined there was high utilization at the same time as cataract surgery. Two new codes, 66987 and 66988, are now in effect describing when both ECP and cataract surgery are performed in the same surgical session. Due to the creation of these codes, 66711, 66984 and 66982 have descriptor changes, which is underlined below.
66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation
66987 (same description above) with endoscopic cyclophotocoagulation
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation
66988 (same description above) with endoscopic cyclophotocoagulation
66711 Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens
Payment — Although the Academy did provide CMS with guidance on how to establish fair pricing of these new codes, the recommendations were rejected. Each Medicare Administrative Contractor (MAC) will establish the allowable for the new codes 66987 and 66988, rather than having specific relative value units (RVUs) attributed to the codes. To verify allowables, check your MAC website for its fee schedule.
Documentation —Be sure your documentation supports the code that you submit for reimbursement. Include both the cataract diagnosis and reason for the essential community provider (ECP) on the claim. If there’s no policy, review the Coding Coach for the typically covered diagnostic codes.
Bundling — The table indicates how this family of codes is bundled together, along with eye visit codes. For a full list of all Correct Coding Initiative (CCI) edits impacting 66987 and 66988, go to:
||Possible to Unbundle (-59)
Commercial Payers and New Codes
Advise your staff to verify coverage with commercial payers on these new and changed codes. Although they are required to implement changes, not all do so on Jan. 1. Ask about policies and allowables to confirm their systems have been updated with the new codes.
Additional information on these and other changes can be found in the recorded webinar 2020 Coding Update.
About the author: Jennifer S. Edgar, CPC, CPCO, OCS, OCSR, is a coding specialist and manager in the Academy’s Coding and Reimbursement section. She also is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.