Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27509
LCD Title
Extended Ophthalmoscopy
Contractor’s Determination Number
L27509
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after 08/01/2008
Revision Ending Date
08/31/2008
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Indications and Limitations
Extended ophthalmoscopy includes a drawing of the retina observed through a dilated pupil (unless dilation is clinically contraindicated), a written interpretative report, and a documented plan of treatment.
A single drawing will be reimbursed if it documents clinically significant details that cannot be adequately or succinctly communicated in writing alone. Sequential drawings will only be covered when they describe a condition within the eye that is subject to change in extent, appearance, or size, and where that change would directly affect the management.
Extended ophthalmoscopy is not one of the elements included under General Ophthalmological Services. It would generally be performed after these services are furnished.
Indications
Extended ophthalmoscopy is indicated for a wide range of posterior segment pathology, when the level of examination requires a complete view of the back of the eye and documentation is greater than that required for a routine ophthalmoscopy.
An extended ophthalmoscopy may be considered medically reasonable and necessary when any one of the following is present.
- Neoplasm
- Malignant
- Evaluation of choroidal nevus for malignant transformation
- Trauma
- Old intraocular foreign body
- Penetrating wound to the orbit with retained foreign body
- Blunt injury to eye or adnexa
- Abnormalities of the Macula
- Macular hole
- Clinically significant macular edema
- Age-related macular degeneration or central serous retinopathy
- Abnormalities of the Retina
- Retinal detachment
- Retinal defect
- Suspected retinal tear with sudden onset of symptomatic floaters or vitreous hemorrhage
- Hemorrhage, edema, ischemia, exudates or deposits, hereditary retinal dystrophies, or peripheral degeneration
- Retinoschisis
- Retinal cysts
- Retinal edema
- Diabetic retinopathy
- Abnormalities of the Choroid
- Chorioretinal scars
- Choroidal degeneration
- Dystrophies
- Hemorrhages
- Rupture
- Detachment
- Other
- High risk medication for retinopathy or optic neuropathy
- Retinal vascular occlusion
- Posterior vitreous detachment
- Sudden or transient visual loss
- Posterior scleritis
- Vogt-Koyanagi syndrome
- Degenerative disorders of the globe
- Endophthalmitis
- Systemic disease associated with retinal disease
- High axial length myopia
- Metamorphopsia
- Disorders of the vitreous body
Limitations
- Extended ophthalmoscopy should not be routinely used on both eyes of every patient on all visits.
- Routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, but these should still be documented in the patient’s medical record.
- If indirect ophthalmoscopy is done without a drawing, the service is not separately payable and will be considered part of a general ophthalmologic exam (92002-92014).
- Extended ophthalmoscopy (codes 92225, 92226) performed during the global surgery period of an ophthalmologic surgery procedure by the same provider doing the surgery will not be separately payable unless unrelated to the condition for which the surgery was performed.
- Extended ophthalmoscopy will be considered not medically necessary if there is insufficient drawing.
- Extended ophthalmoscopy will be considered not medically necessary if the medical record does not document the interpretation.
- Extended ophthalmoscopy will be considered not medically necessary when it replaces a routine ophthalmoscopy without documented need of this more extensive examination.
- When other ophthalmologic tests (e.g., fundus photography, fluorescein angiography, ultrasound, etc.) have been performed, extended ophthalmoscopy will be considered medically unnecessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (NON-DUPLICATIVE) information.
Coverage Topic
Diagnostic tests and X-Rays
Coding Information
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
051X | Clinic-general classification |
076X | Treatment or observation room-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
92225 | OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; INITIAL |
92226 | OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; SUBSEQUENT |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
094.85 | SYPHILITIC RETROBULBAR NEURITIS |
115.02 | HISTOPLASMA CAPSULATUM RETINITIS |
115.92 | HISTOPLASMOSIS RETINITIS UNSPECIFIED |
130.2 | CHORIORETINITIS DUE TO TOXOPLASMOSIS |
190.0 | MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID |
190.5 | MALIGNANT NEOPLASM OF RETINA |
190.6 | MALIGNANT NEOPLASM OF CHOROID |
190.8 | MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE |
198.4 | SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM |
198.89 | SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
224.5 | BENIGN NEOPLASM OF RETINA |
224.6 | BENIGN NEOPLASM OF CHOROID |
225.1 | BENIGN NEOPLASM OF CRANIAL NERVES |
228.03 | HEMANGIOMA OF RETINA |
228.09 | HEMANGIOMA OF OTHER SITES |
237.70 | NEUROFIBROMATOSIS UNSPECIFIED |
237.71 | NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE |
237.72 | NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS |
250.00 | DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.01 | DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.02 | DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.03 | DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED |
250.10 | DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.11 | DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.12 | DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.13 | DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
250.20 | DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.21 | DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.22 | DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.23 | DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED |
250.30 | DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.31 | DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.32 | DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.33 | DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED |
250.40 | DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.41 | DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.42 | DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.43 | DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
250.50 | DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
250.51 | DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
250.52 | DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
250.53 | DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
282.41 | SICKLE-CELL THALASSEMIA WITHOUT CRISIS |
282.42 | SICKLE-CELL THALASSEMIA WITH CRISIS |
282.60 | SICKLE-CELL DISEASE UNSPECIFIED |
282.64 | SICKLE-CELL/HB C DISEASE WITH CRISIS |
282.68 | OTHER SICKLE-CELL DISEASE WITHOUT CRISIS |
PURULENT ENDOPHTHALMITIS UNSPECIFIED - VITREOUS ABSCESS | |
SYMPATHETIC UVEITIS - OTHER ENDOPHTHALMITIS | |
DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED - OTHER DEGENERATIVE DISORDERS OF GLOBE | |
HYPOTONY OF EYE UNSPECIFIED - FLAT ANTERIOR CHAMBER OF EYE | |
DEGENERATED GLOBE OR EYE UNSPECIFIED - LEUCOCORIA | |
FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY MAGNETIC IN OTHER OR MULTIPLE SITES | |
FOREIGN BODY INTRAOCULAR UNSPECIFIED - INTRAOCULAR FOREIGN BODY IN OTHER OR MULTIPLE SITES | |
360.81 | LUXATION OF GLOBE |
360.89 | OTHER DISORDERS OF GLOBE |
360.9 | UNSPECIFIED DISORDER OF GLOBE |
RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL | |
RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS | |
361.2 | SEROUS RETINAL DETACH |
RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH | |
361.81 | TRACTION DETACH OF RETINA |
361.89 | OTHER FORMS OF RETINAL DETACH |
361.9 | UNSPECIFIED RETINAL DETACH |
BACKGROUND DIABETIC RETINOPATHY - BACKGROUND RETINOPATHY UNSPECIFIED | |
HYPERTENSIVE RETINOPATHY - RETINAL VASCULITIS | |
362.21 | RETROLENTAL FIBROPLASIA |
362.29 | OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY |
RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA | |
RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM | |
MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA | |
PERIPHERAL RETINAL DEGENERATION UNSPECIFIED - SECONDARY VITREORETINAL DEGENERATIONS | |
HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE | |
RETINAL HEMORRHAGE - OTHER RETINAL DISORDERS | |
FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL | |
DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY | |
363.20 | CHORIORETINITIS UNSPECIFIED |
363.21 | PARS PLANITIS |
363.22 | HARADA'S DISEASE |
CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA | |
CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID | |
HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL | |
363.61 | CHOROIDAL HEMORRHAGE UNSPECIFIED |
363.62 | EXPULSIVE CHOROIDAL HEMORRHAGE |
363.63 | CHOROIDAL RUPTURE |
363.70 | CHOROIDAL DETACH UNSPECIFIED |
363.71 | SEROUS CHOROIDAL DETACH |
363.72 | HEMORRHAGIC CHOROIDAL DETACH |
363.8 | OTHER DISORDERS OF CHOROID |
363.9 | UNSPECIFIED DISORDER OF CHOROID |
364.00 | ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED |
PRIMARY IRIDOCYCLITIS - SECONDARY IRIDOCYCLITIS NONINFECTIOUS | |
364.10 | CHRONIC IRIDOCYCLITIS UNSPECIFIED |
364.11 | CHRONIC IRIDOCYCLITIS IN DISEASES CLASSIFIED ELSEWHERE |
FUCHS' HETEROCHROMIC CYCLITIS - VOGT-KOYANAGI SYNDROME | |
364.3 | UNSPECIFIED IRIDOCYCLITIS |
364.41 | HYPHEMA OF IRIS AND CILIARY BODY |
364.42 | RUBEOSIS IRIDIS |
ESSENTIAL OR PROGRESSIVE IRIS ATROPHY - OTHER IRIS ATROPHY | |
IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY - EXUDATIVE CYST OF PARS PLANA | |
ADHESIONS OF IRIS UNSPECIFIED - RECESSION OF CHAMBER ANGLE OF EYE | |
364.81 | FLOPPY IRIS SYNDROME |
364.89 | OTHER DISORDERS OF IRIS AND CILIARY BODY |
364.9 | UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY |
PREGLAUCOMA UNSPECIFIED - OCULAR HYPERTENSION | |
OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA | |
PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA | |
365.31 | CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE |
365.32 | CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE |
GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES | |
PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS | |
GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA | |
HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA | |
365.9 | UNSPECIFIED GLAUCOMA |
SUBJECTIVE VISUAL DISTURBANCE UNSPECIFIED - PSYCHOPHYSICAL VISUAL DISTURBANCES | |
VISUAL FIELD DEFECT UNSPECIFIED - HETERONYMOUS BILATERAL FIELD DEFECTS | |
NIGHT BLINDNESS UNSPECIFIED - OTHER NIGHT BLINDNESS | |
368.8 | OTHER SPECIFIED VISUAL DISTURBANCES |
368.9 | UNSPECIFIED VISUAL DISTURBANCE |
DEFORMITY OF ORBIT UNSPECIFIED - DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY | |
376.50 | ENOPHTHALMOS UNSPECIFIED AS TO CAUSE |
376.51 | ENOPHTHALMOS DUE TO ATROPHY OF ORBITAL TISSUE |
376.52 | ENOPHTHALMOS DUE TO TRAUMA OR SURGERY |
376.6 | RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT |
377.00 | PAPILLEDEMA UNSPECIFIED |
PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE - FOSTER-KENNEDY SYNDROME | |
OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY | |
DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA | |
OPTIC NEURITIS UNSPECIFIED - OTHER OPTIC NEURITIS | |
ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE | |
DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS | |
379.07 | POSTERIOR SCLERITIS |
VITREOUS DEGENERATION - OTHER DISORDERS OF VITREOUS | |
379.32 | SUBLUXATION OF LENS |
379.34 | POSTERIOR DISLOCATION OF LENS |
714.0 | RHEUMATOID ARTHRITIS |
CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS - MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS | |
VITREOUS ANOMALIES CONGENITAL - OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT | |
759.5 | TUBEROUS SCLEROSIS |
759.6 | OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED |
759.82 | MARFAN SYNDROME |
871.5 | PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY |
871.6 | PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY |
871.7 | UNSPECIFIED OCULAR PENETRATION |
871.9 | UNSPECIFIED OPEN WOUND OF EYEBALL |
921.3 | CONTUSION OF EYEBALL |
958.1 | FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA |
UNSPECIFIED CHILD ABUSE - OTHER CHILD ABUSE AND NEGLECT | |
996.53 | MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS |
PENICILLINS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - OTHER AND UNSPECIFIED VACCINES AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE | |
V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9 code(s). The submitted CPT/HCPCS code should describe the service performed.
- Indications for the testing should be entered in the medical record on a case-by-case and eye-by eye basis.
- Retinal drawings meeting the specifications indicated in this policy must be maintained in the patient’s record along with an interpretation that affects the plan of treatment.
- There must be a separate detailed sketch.
- All items noted must be identified and labeled.
- Drawings in 4-6 standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.
- Optic nerve abnormalities should be separately drawn.
- An extensive scaled drawing must accurately represent normal, abnormal and common findings such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears or tumors.
- Documentation in the patient’s medical record for a diagnosis of glaucoma (ICD-9-CM codes 365.00-365.9) must include all of the following:
- A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment,
- Documentation of cupping, disc rim, pallor, and slope,
- Documentation of any surrounding pathology around the optic nerve.
- Documentation specific to the method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.
- The medical record should document that the pupil was dilated and what drug was used.
- All findings and a plan of action should be documented in notes.
- Although routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, these should still be documented in the patient’s medical record.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27509
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
08/01/2008 |
L27509 |
LCD effective 08/01/2008 for DC Part A, Maryland Part A, and Pennsylvania Part A. LCD is now effective for DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
05/23/2008 |
L27509 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D33 |
Original LCD posted for comment. |
Last Reviewed On
07/31/2008
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