How To Use CPT Code 92201

CPT 92201 describes the procedure for ophthalmoscopy with retinal drawing and scleral depression of peripheral retinal disease. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 92201?

CPT 92201 can be used to describe the extended ophthalmoscopy procedure performed by a healthcare provider. This procedure involves the use of an indirect ophthalmoscope and scleral depression to examine the posterior segment and periphery of the fundus. The provider creates a retinal drawing with interpretation and writes a report based on their findings. This code is used for an extended ophthalmoscopy with retinal drawing on one or both eyes.

2. Official Description

The official description of CPT code 92201 is: ‘Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.’

3. Procedure

1. The healthcare provider begins by instilling dilating and numbing drops in the patient’s eye to prepare for the examination.
2. Using a direct ophthalmoscope, the provider performs a routine ophthalmoscopy to assess the general condition of the eye.
3. If the provider identifies signs of serious retinal or posterior segment disease, they proceed with an extended ophthalmoscopy.
4. For the extended ophthalmoscopy, the provider switches to an indirect ophthalmoscope and uses a bright light source and a hand-held indirect lens to meticulously examine the interior of the eye.
5. To visualize the peripheral part of the retina that may be obscured by the iris or crystalline lens, the provider inserts a scleral depressor between the globe and the orbit.
6. The scleral depression displaces the retina inward and elevates it, allowing the provider to better identify poorly defined lesions, retinal holes, tears, or vitreoretinal adhesions.
7. During the examination, the provider creates one or more detailed retinal drawings to document the extent of their examination.
8. Based on their findings, the provider interprets the retinal drawings and prepares a report that includes their impression and diagnosis.

4. Qualifying circumstances

CPT 92201 is used when there is a need to evaluate and document peripheral retinal disease, such as retinal tear, retinal detachment, or retinal tumor. The procedure involves the use of an indirect ophthalmoscope and scleral depression to visualize the peripheral part of the retina. It is important to note that this code should only be reported if a serious retinal problem has been documented during a routine ophthalmoscopy, and the extended ophthalmoscopy is medically necessary to further evaluate the condition.

5. When to use CPT code 92201

CPT code 92201 should be used when there is a need to perform an extended ophthalmoscopy with retinal drawing and scleral depression to evaluate and document peripheral retinal disease. It is important to ensure that the extended ophthalmoscopy is medically necessary and supported by the findings of a routine ophthalmoscopy. This code should be reported for each eye if the procedure is performed bilaterally.

6. Documentation requirements

To support a claim for CPT 92201, the healthcare provider must document the following information:

• Documentation of a serious retinal problem identified during a routine ophthalmoscopy
• Retinal drawings that reveal the extent of the examination, with appropriate labels and standard colors
• Interpretation of the retinal drawings, including findings and impression
• Diagnosis justifying the extended ophthalmoscopy

7. Billing guidelines

When billing for CPT 92201, ensure that the extended ophthalmoscopy is medically necessary and supported by the findings of a routine ophthalmoscopy. It is important to document a serious retinal problem to justify the use of this code. Additionally, check with the payer to determine if fundus photography can be reported separately or if it is bundled into the payment for the extended ophthalmoscopy. It is also important to be familiar with the payer’s coverage policies for specific conditions and to ensure that the retinal drawings are of sufficient detail and maintained in the patient’s record.

8. Historical information

CPT 92201 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs an extended ophthalmoscopy with retinal drawing and scleral depression to evaluate a patient with a suspected retinal tear.
2. During an examination, a provider uses an indirect ophthalmoscope and scleral depression to assess a patient with a retinal detachment.
3. A healthcare provider performs an extended ophthalmoscopy with retinal drawing and scleral depression to evaluate a patient with a suspected retinal tumor.
4. During an examination, a provider uses an indirect ophthalmoscope and scleral depression to assess a patient with peripheral retinal disease.
5. A healthcare provider performs an extended ophthalmoscopy with retinal drawing and scleral depression to evaluate a patient with a retinal defect without detachment.
6. During an examination, a provider uses an indirect ophthalmoscope and scleral depression to assess a patient with choroidal detachment.