92225: How Do You Determine Medical Necessity For Billing Twice?

Published: 14th March 2011
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Can you shed some light on billing 92225 or 92226 with modifier 50, RT/LT, or two units for a patient following a pseudotumor cerebri in a nursing home? How do you find out medical necessity for billing twice?

Both 92225 (ophthalmoscopy, extended, with retinal drawing (example for retinal detachment melanoma], with interpretation and report; initial) and 92226 (…subsequent) are inherently unilateral, so you can get reimbursement for extended opthalmoscopies (EOs) performed on both eyes provided the optometrist shows medical necessity for both. You must use ICD-9 codes illustrating medical necessity for each eye. Do not assume that both eyes have the same diagnosis.

Check with your insurer's policy for diagnosis codes that support medical necessity. Always code diagnoses based on the OD's documentation. The range of accepted codes is very wide. For example, insurers may accept 362.83 (Retinal edema) and 377.00 (Papilledema, unspecified) to prove medical necessity for an EO.

For the initial ophthalmoscopy performed on both eyes, use 92225-RT and 92225-LT. On the other hand, you may report the service once and append modifier 50 (92225-50). If a subsequent drawing is required on a different date of service, you would report 92226-50 on one line or on separate lines with RT/LT. Some insurers may follow Medicare's requirement of reporting the code once added with modifier 50 (Bilateral procedure).

Other payers may want the code reported twice with modifier 50 appended to the second line whereas others may want modifiers LT (left side) in separate lines.

Even though your inquiry deals with newborns who are not on Medicare, you may want to spotlight Medicare's payment and documentation policies for 92225 and 92226. The 2011 Medicare Physician Fee Schedule doesn't apply a bilateral procedure payment adjustment to these codes. Documentation policies may need a special size of the drawing using different colors and most policies need a detailed drawing. In addition, a legible narrative report of findings is needed.

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