Ask any insurance auditor what creates the largest area of concern for any ophthalmic physician—special testing related to the retina/posterior pole. If you look at the collective array of special ophthalmic procedures that the average optometrist performs, the majority of tests are for the retina. The retina has long been a popular topic of discussion within our professional clinical journals, but the average OD hasn’t been actively managing retinal conditions. These days, however, OD’s can be intimately involved in diagnosing retinal disease and in the active management of many retinal conditions. With the implementation of the ICD-10, greater scrutiny is being placed upon claims data relating to specific diagnoses and medical necessity. Therefore, there are a few things to keep in mind when coding for retinal examinations and/or special ophthalmic procedures related to the retina.

1. According to the CPT, when performing any 920XX code, dilation is not mandatory, but defined as, “often includes, as indicated.”¹

2. According to the 1997 CMS E&M Guidelines that govern any 992XX code, when the retinal components of a single system eye examination are performed, they must be performed through a dilated pupil unless contraindicated because of age or medical reasons.² Keep in mind that good medical record protocol dictates that the dilating agent(s) should be listed.

3. A statement of medical necessity for any return office visits to your practice or for any ordered special ophthalmic procedures should be clearly stated in your assessment and plan for the office visit performed that day. Keep in mind that medical necessity rules the day—you must ensure that any test that you are ordering or performing must play a role in clinically managing the patient and can’t be performed just to document a condition. In fact, the ICD-10 is creating areas of audit exposure due to the specificity of the codes.

a. Here is a clinical example of a question that get asked by colleagues far more frequently than I would like to admit—“Can I do a fundus photograph (CPT 92250) on a patient with a diagnosis of E11.9 (Type 2 Diabetes without Complications)?” I see people trying to submit this combination far too frequently. Look at what you are telling the carrier: here is a patient “without complications” on whom you have performed a fundus photograph. Where would the medical necessity argument be here? It is inappropriate to document a normal retina in a diabetic and bill a carrier for it, unless the patient has unexplained symptoms or signs of a documented visual disturbance.

4. According to the CPT, any special ophthalmic test that has a specific definition as a separate and distinct procedure by the virtue of having its own CPT code is not part of any office visit whether a 920XX or 992XX code. It also means that they can be ordered and performed by the physician on the same date of service as the office visit as long as they are performed in accordance with the National Correct Coding Initiative Edits and meet all requirements specific to your geographic location for medical necessity. The CPT section on special ophthalmic tests has the preamble:

a. Describes services in which a special evaluation of the part of the visual system is made, which goes beyond the services included under general ophthalmological services or in which special treatment is given.
b. Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services.¹

5. All special ophthalmic tests are still subject to the MPPR (Multiple Procedure Payment Reduction) that was rolled out in 2013. This comes into play when you are performing multiple special ophthalmic procedures on the same day that full payment is made for the TC (technical component) service with the highest payment under the MPFS. Payment is made at 75% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day.³  

6. All special ophthalmic tests require an Interpretation and Report that is distinct and separate from any notes contained in the office visit itself (if performed). A special ophthalmic test is not deemed to be complete (or billable) until the physician has completed the I&R. The essential elements of an Interpretation and Report are:

a. Clinical findings—pertinent findings regarding the test results
b. Reliability of the test
c. Comparative Data—comparison to previous test results (if applicable)
d. Clinical Management—how the test results will affect management of the condition/disease, i.e.:

i. Change, increase or stop medication
ii. Recommendation for surgery
iii. Recommendation for further diagnostic testing
iv. Referral to a specialist or sub-specialist for additional treatment

7. When performing a special ophthalmic test, you are essentially referring a patient to yourself and therefore you need to place the name and NPI of the referring physician (even if it is yourself) into box 17 and 17B respectively, of the CMS 1500 form to allow the carrier to properly process it and to avoid the claim rejection CO-16 “Claim/service lacks information which is needed for adjudication.”⁴

You may not like the rules or how MACRA is going to change the economics of how you get paid in the future for managing retinal conditions, but it is up to you to keep these rules at the forefront of your mind when performing your clinical care. Keep in an important principle—we don’t perform coding and billing; we provide clinical care and our clinical medical record is our written proof of the care we provided.  The CPT code that is created for an encounter or procedure is nothing more than the translation of the medical care delivered into a five-character code. Profitability is nothing more than a by-product of the standard of care, a thorough and accurate medical record, and the translation of the clinical care provided into a CPT code used in accordance with the laws we have to follow.  

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1. CPT: Professional Edition. American Medical Association;2016:591 2. Evaluation & Management Guidelines, Centers For Medicare and Medicaid Services;1997. 3. Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm7848.pdf. 4. Claim Adjustment Reason Codes. Claim Adjustment Reason Codes. http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/.