The CPT codes for extended ophthalmoscopy, initial (92225) and subsequent (92226), were retired at the start of the year, having been replaced by two new codes. Although there are some similarities between them, changes in definitions for the new codes can lead to coding errors if the distinctions are overlooked.
The new codes
First, let’s look at 92201, defined as:
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.1
The first issue to recognize is that this code doesn’t state “initial” or “subsequent.” The second significant issue is that this code is “unilateral or bilateral.” In other words, you’ll receive payment for one service whether you examine one or two eyes. Significantly, 92201 is a peripheral retinal drawing code and requires scleral depression.
The second new code is 92202 and it’s distinctly different from 92201:
Ophthalmoscopy, extended, with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.1
As with 92201, this code isn’t “initial” or “subsequent,” and it has one payment whether one or both eyes require a drawing. However, it doesn’t require scleral depression.
Payer policies will vary somewhat for these two codes. Generally, they’ll require a “large, scaled” drawing. Some policies specify the diameter of the drawing as three to four inches. Some require color. All payers require the drawing be labeled and include an interpretation and report. In addition, the method of examination (dilated, supine and/or type of lens used) needs to be documented.
A review of payer policies reveals covered diagnoses for the new codes. One may assume 92201 will be covered for diseases affecting the peripheral retina, and 92202 will cover macular and optic nerve conditions. Because there’s some overlap, you may see diagnoses that are, at first blush, peripheral but are covered for 92202. On further thought, you’ll note that diseases such as diabetic retinopathy may have peripheral as well as macular manifestations.
Another word of caution: If you repeatedly use a “peripheral” diagnosis for 92202 or an optic nerve diagnosis for 92201, payers may revise policies to narrow covered diagnoses. So use care and thought in selecting the appropriate diagnoses.
Multiple National Correct Coding Initiative (NCCI) edits apply to these codes. Significantly, CPT specifies 92201 and 92202 can’t be billed with each other, and neither can be billed with fundus photography (92250). NCCI agrees. The codes are also bundled under NCCI with intravitreal injection (67028) and most retinal surgeries.
Although 92201 and 92202 are bundled with 92250, the new codes don’t have NCCI edits with scanning computerized ophthalmic diagnostic imaging/optical coherence tomography (92133/92134) or fluorescein angiography (92235). That may change in the future.
Unfortunately, the fee schedule is lower than the retired codes: 92225 and 92226 had a national average payment rate of $28 and $26 respectively; the new codes are valued at $26 (92201) and $16 (92202).2
Can you bill both 92201 and 92202? Perhaps. Patients who have multiple diseases and require both a peripheral and fundus or optic nerve drawing will require meticulous documentation supporting medical necessity for both 92201 and 92202. If you decide both tests are medically necessary, you’ll be required to submit separate drawings, interpretations and diagnoses with the claim for payment.
The second test may be submitted with the XS modifier, “Separate Structure.” However, with the exception of Medicare, payers rarely recognize this modifier and denial is likely. And if the documentation is weak, an audit will result in payment retraction and with the potential to expose you to a wider audit, so use caution.
It’s important to first be sure your charge capture and electronic medical record are configured to accept the new CPT codes. Next, a careful review of the drawing templates is needed. You should have different templates for 92201 and 92202.
And finally, Medicare payer policies require careful review to be sure drawing requirements, covered diagnoses and NCCI edits are fully understood. Understand payer policies before you submit a claim.
Information on NCCI edits is available on the Centers for Medicare and Medicaid Services website (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd). NCCI edits also are available from Medicare carriers and a few commercial vendors. RS
1. AMA CPT 2020 Professional Edition. Chicago, IL: American Medical Association; 2020,
2. Centers for Medicare and Medicaid Services. Physician Fee Schedule Look-Up Tool for 2020. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Publication date not specified. Accessed February 28, 2020.