L28940-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Ophthalmoscopy (L28940)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28940

LCD Title Ophthalmoscopy

Contractor's Determination Number A92225

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869 (f)(1)(A)(i) of the Social Security Act.

Unless other wise specified, italicized text represents quotation from one or more of the following CMS sources: N/A

Indications and Limitations of Coverage and/or Medical Necessity

Extended ophthalmoscopy is an assessment of the posterior segment of the eye (vitreous, retina, optic disc, choroids, etc.) with the pupil dilated using indirect ophthalmoscopy or slit lamp biomicroscopy. These techniques employ an additional diagnostic tool (eg, 3-mirror lens, 20-diopter lens, 90-diopter lens, scleral depression) and include a detailed drawing of the retina. Extended ophthalmoscopy provides a high intensity illumination, stereoscopic, wide field of view of the ocular fundus for detection and/or evaluation of vitreoretinal pathology.

Extended ophthalmoscopy codes are reserved for the meticulous evaluation of the eye in detailed documentation of a severe ophthalmologic problem needing continued follow-up, which cannot be sufficiently evaluated by photography.

Medicare will consider ophthalmoscopy (CPT Codes 92225, 92226) to be medically reasonable and necessary if any one of the following circumstances is present:

• The patient has a malignant neoplasm of the retina or choroid. This may appear as a single, round or oval, slightly elevated, gray or nonpigmented lesion.

• The patient has a retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing.

• The patient has retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration.

• The patient has retinal detachment with or without retinal defect. The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as “a curtain came down over my eyes.”

• The patient has retinal defects without retinal detachment.

• The patient has diabetic retinopathy (e.g., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation.

• The patient has experienced sudden visual loss or transient visual loss. This may be described as trouble seeing or vision going in and out.

• The patient has chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment.

• The patient has Vogt-Koyanagi syndrome. This disease is characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea.

• The patient has sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye.

• The patient has disorders of the vitreous body (e.g., vitreous hemorrhage or posterior vitreous detachment). Spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders.

• The patient has posterior scleritis. Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field.

• The patient has degenerative disorders of the globe.

• The patient has retinoschisis and retinal cysts. Patients may complain of light flashes and floaters.

• The patient has signs and symptoms of endophthalmitis which may include severe pain, redness, photophobia, and profound loss of vision.

• The patient has glaucoma or is a glaucoma suspect. This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve. The patient's medical record must meet the documentation requirements set forth in this policy (see Documentation Requirements).

In all instances extended ophthalmoscopy must be medically necessary. It must add information not available from the standard evaluation services and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means.

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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

085x Critical Access Hospital

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.

0920 Other Diagnostic Services - General Classification

CPT/HCPCS 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

115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED

130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

224.5 BENIGN NEOPLASM OF RETINA

224.6 BENIGN NEOPLASM OF CHOROID

225.1 BENIGN NEOPLASM OF CRANIAL NERVES

228.03 HEMANGIOMA OF RETINA 360.00 - 360.04 opens in

new window PURULENT ENDOPHTHALMITIS UNSPECIFIED - VITREOUS ABSCESS

360.11 SYMPATHETIC UVEITIS

360.12 PANUVEITIS

360.13 PARASITIC ENDOPHTHALMITIS UNSPECIFIED

360.19 OTHER ENDOPHTHALMITIS

360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA

360.23 SIDEROSIS OF GLOBE

360.24 OTHER METALLOSIS OF GLOBE

360.50 FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED

360.52 FOREIGN BODY MAGNETIC IN IRIS OR CILIARY BODY

360.54 FOREIGN BODY MAGNETIC IN VITREOUS

360.55 FOREIGN BODY MAGNETIC IN POSTERIOR WALL

360.60 FOREIGN BODY INTRAOCULAR UNSPECIFIED

360.64 FOREIGN BODY IN VITREOUS

360.65 FOREIGN BODY IN POSTERIOR WALL OF EYE

361.00 - 361.07 opens in new window

361.10 - 361.19 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL

RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS

361.2 SEROUS RETINAL DETACH 361.30 - 361.33 opens in

new window RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH

361.81 - 361.89 opens in

new window TRACTION DETACH OF RETINA - OTHER FORMS OF RETINAL DETACH

362.1 * BACKGROUND DIABETIC RETINOPATHY

362.2 * PROLIFERATIVE DIABETIC RETINOPATHY

362.3 * NONPROLIFERATIVE DIABETIC RETINOPATHY NOS

362.5 * MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.6 * SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.7 * DIABETIC MACULAR EDEMA

362.10 - 362.18 opens in

new window BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS

362.21 - 362.29 opens in

new window RETROLENTAL FIBROPLASIA - OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.30 - 362.37 opens in

new window RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA

362.40 - 362.43 opens in new window

362.50 - 362.57 opens in new window

362.60 - 362.66 opens in new window

362.70 - 362.77 opens in new window

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

362.81 RETINAL HEMORRHAGE

362.82 RETINAL EXUDATES AND DEPOSITS

362.83 RETINAL EDEMA

362.84 RETINAL ISCHEMIA

363.00 - 363.08 opens in new window

363.10 - 363.15 opens in new window

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 363.30 - 363.35 opens in

new window CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA

363.40 - 363.43 opens in

new window CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID

363.50 - 363.57 opens in new window

363.61 - 363.63 opens in

HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL

new window CHOROIDAL HEMORRHAGE UNSPECIFIED - CHOROIDAL RUPTURE

363.70 - 363.72 opens in

new window CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH

364.00 - 364.05 opens in

new window ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - HYPOPYON

364.24 VOGT-KOYANAGI SYNDROME

365.00 - 365.06 opens in new window

365.10 - 365.15 opens in new window

PREGLAUCOMA UNSPECIFIED - PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.20 - 365.24 opens in new window

365.31 - 365.32 opens in new window

365.41 - 365.44 opens in new window

365.51 - 365.59 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE- CLOSURE GLAUCOMA CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE - CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 - 365.65 opens in new window

365.70 - 365.74 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA GLAUCOMA STAGE, UNSPECIFIED - INDETERMINATE STAGE GLAUCOMA

365.81 - 365.89 opens in

new window HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA

368.11 SUDDEN VISUAL LOSS

368.12 TRANSIENT VISUAL LOSS

368.15 OTHER VISUAL DISTORTIONS AND ENTOPTIC PHENOMENA

376.6 RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT

377.00 PAPILLEDEMA UNSPECIFIED 377.10 - 377.16 opens in

new window OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY

377.21 - 377.24 opens in

new window DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.33 NUTRITIONAL OPTIC NEUROPATHY

377.34 TOXIC OPTIC NEUROPATHY 377.41 - 377.49 opens in

new window ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE

379.07 POSTERIOR SCLERITIS 379.21 - 379.29 opens in

new window VITREOUS DEGENERATION - OTHER DISORDERS OF VITREOUS

379.32 SUBLUXATION OF LENS

379.34 POSTERIOR DISLOCATION OF LENS

743.51 - 743.59 opens in new window

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

871.0 - 871.9 opens in new window

OCULAR LACERATION WITHOUT PROLAPSE OF INTRAOCULAR TISSUE - UNSPECIFIED OPEN WOUND OF EYEBALL

921.3 CONTUSION OF EYEBALL

998.82 CATARACT FRAGMENTS IN EYE FOLLOWING CATARACT SURGERY

* To ensure reimbursement for this service when billing ICD-9-CM code 362.07, dual diagnoses must be submitted. An ICD-9-CM code from the following diagnosis codes 362.01-362.03, 362.05, or 362.06 (representing diabetic retinopathy) must be reported with ICD-9-CM code 362.07 (diabetic macular edema).

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (eg, office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the extended ophthalmoscopy exam. The medical records must include the following:

• The complaint or symptomatology necessitating the extended ophthalmoscopy exam

• Notation that the eye examined was dilated and the drug used

• The method of examination (eg, lens, instrument used)

• A detailed drawing of the retina showing anatomy in the patient as seen at time of examination, including the pathology found and a legible narrative report of the findings

• An assessment of the change from previous examinations when performing follow-up services (92226)

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the ophthalmoscopy exam results and interpretation, along with copies of the ordering/referring physician’s order for the ophthalmoscopy. The physician must state the clinical indication/medical necessity for the ophthalmoscopy in the order for the exam.

Documentation in the medical record for a diagnosis of glaucoma (ICD-9 Code 365.00-365.9) must include all of the following:

• a detailed drawing of the optic nerve,

• documentation of cupping, disc rim, pallor, and slope, and

• documentation of any surrounding pathology around the optic nerve.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Yanoff. (2004). Ophthalmology(2nd ed.). St. Louis, MO: Mosby.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation

with advisory groups, which includes representatives from The Ophthalmology and Optometrist Societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number: 1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added new diagnosis codes 365.05, 365.06, and 365.70

-365.74. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28940) replaces LCD L1025 as the policy in notice. This document (L28940) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0920 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

92225 descriptor was changed in Group 1 92226 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change