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Jurisdiction 11 Part B
Medical Review Probe: Outpatient Ophthalmology Procedure Codes

The J11 A/B MAC Medical Review department will perform a service-specific prepay probe review on outpatient claims in North Carolina, South Carolina, Virginia and West Virginia. Data analysis identified 13 ophthalmology outpatient services with significant frequency in these states. Further analysis indicated the procedure codes listed below as most frequently billed ophthalmology codes for North Carolina, South Carolina, Virginia and West Virginia. Claims review will be performed on approximately 100 claims per state for each of the procedure codes selected. The procedure codes identified are:

  • CPT code 92235 (Fluorescein Angiography (Includes multiframe imaging) with interpretation and report)
  • CPT code 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program: comprehensive, new patient, one or more visits)
  • CPT code 92014 (Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program: comprehensive, established patient, one or more visits)
  • CPT code 92012 (Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program: intermediate established patient)
  • CPT code 92083 (Visual field examination unilateral or bilateral, with interpretation and report: extended examination (e.g., Goldman Visual Fields with at least three quantitative, automated threshold perimetry, Octopus Program G-1, 32 or 42, Humphrey Visual Field ANA)
  • CPT code 92250 (Fundus photography with interpretation and report)
  • CPT code 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program: intermediate, new patient)
  • CPT code 92226 (Ophthalmoscopy, extended with retinal drawing (e.g., for retinal detachment, melanoma) with interpretation and report: subsequent)
  • CPT code 92225 (Opthalmoscopy, extended with retinal drawing (e.g., for retinal detachment, melanoma) with interpretation and report: initial)
  • CPT code 92020 (Gonioscopy separate procedure)
  • CPT code 92285 (External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography)
  • CPT code 76514 (Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral determination of corneal thickness)
  • CPT code 92015 (Determination of refractive state)

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

Palmetto GBA
J11 Part B Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC  29202-3238

Or fax it to (803) 699-2434

Providers should ensure the accuracy of their billing and send the following documentation when responding to the ADRs:

  • Patient’ medical record
  • Chart notes
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Physician progress notes
  • Please submit all documentation to support the medical necessity of services/ procedure code billed
  • If you question the legibility of your signature, you may submit a signature log or an attestation statement in your ADR response. Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable. Patient identification, date of service and provider of the service should be clearly identified on the submitted documentation.

Completed review results will be posted to the Palmetto GBA Web site. Individual providers with significant denials will be contacted for one-on-one education. Questions regarding this review may be directed to the Medical Review department at (803) 763-7491.

 

last updated on 04/11/2012
ver 1.0.37