In order for Palmetto GBA to consider CPT code 92225 (Ophthalmoscopy, extended, with retinal drawing, interpretation and report; initial) for payment, the patient’s medical record must include documentation of retinal pathology to justify this detailed examination. A detailed retinal drawing is also required in the patient’s medical record.
- The Palmetto GBA Local Coverage Determination (LCD) 'Ocular Photography and Ophthalmoscopy' includes a complete listing of covered ICD-9 codes for this procedure:
Requirements for retinal drawings:
- Documentation of the retinal drawing must be maintained in the patient's medical record, along with the interpretation that affects the plan of treatment, and must be available to the carrier upon request
- 'Complete drawings' must provide sufficient detail as to the extent of a retinal detachment or the location of retinal holes in relation to major structures. Areas of traction, vitreous opacities, hemorrhage, etc. should be all drawn and clearly labeled to facilitate follow-up, referral to another physician or proposed surgical treatment.
- The retinal drawing must be labeled and include:
- Major landmarks
- Lesions
- Surrounding pathology
- The exact size of the drawing is not as important as the information in the form of detail and relationships of ocular structures that it conveys. Drawings in four to six standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.
- Submit CPT code 92226 for subsequent retinal drawing. Documentation in the patient's medical record must indicate that an initial retinal drawing was performed and that coverage criteria were met for the initial procedure.