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Ophthalmology Coding Alert

Retina Specialists Beware: Getting Reimbursed for 92225 Can Get Complicated

- Published on Wed, Sep 01, 1999
Extended ophthalmoscopy (92225, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial drawing; 92226, subsequent drawings) is an essential tool for retina specialists, and some general ophthalmologists do it as well. But there are sometimes problems getting paid. These problems stem from the fact that retina specialists tend to use these codes much more than general ophthalmologists do.

Our orientation here is retina and vitreous, so we do this procedure a lot, explains Paul Fernandes, billing manager for Long Island Vitreo Retinal Consultants, a six-ophthalmologist practice in Great Neck, NY. Recently, Fernandes opened his mail to find a letter from Medicare stating that one of his physicians had been audited.

They compared him to 900 ophthalmologists, and said he was overutilizing 92225, recalls Fernandes. They said that they were comparing him to his peers, but they were comparing him to all ophthalmologists, not specifically retina specialists.

Fernandes called his Medicare carrier immediately. I explained to the young lady who was responsible for the audit that we are retinal specialists, and that we have to do 92225 when we see many patients. The representative understood, and said that the matter was solved.

Protect Yourself: Put it in Writing

But that wasnt enough for Fernandes. I wrote a letter saying that we are retina specialists, and explaining why we have medical necessity to do 92225, he says. (For the basic text of this letter, which Fernandes has many opportunities to use, see box below.) The billing manager sent the letter to the representative by certified mail, along with a cover letter from him reiterating the conversation he had with the rep. Its important to follow up with a letter, says Fernandes. Thats because at Medicare, good people get promoted up and out of the reach of the provider. You need to have a record.

He also keeps a copy of the letter in a file called Medicare correspondence, and he attaches a copy of the postal receipt, showing that the letter was signed for, to his copy of the letter.

Especially with correspondence, believes Fernandes, you need to save all correspondence not because the Medicare representative (or commercial HMO or Blue Cross/Blue Shield representative) is incompetent, he says, but because you will need it in the future. Youre reinforcing a conversation you had, so two years down the line, when the doctor says, Hey, were being audited for doing too many extended ophthalmoscopies, you can say, I had a conversation with the representative, and she said it was okay as long as we showed medical necessity. If you dont have the letter, and only have a memory of that conversation, you could [...]

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