How To Use CPT Code 92202

CPT 92202 describes the procedure of extended ophthalmoscopy with drawing of the optic nerve or macula, along with interpretation and report. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 92202?

CPT 92202 can be used to report the extended ophthalmoscopy procedure, which involves the use of an indirect ophthalmoscope with a bright light and a hand-held indirect lens. During this procedure, the provider creates a drawing of the optic nerve or macula and interprets the findings, followed by writing a report. This code is used when the procedure is performed on one or both eyes.

2. Official Description

The official description of CPT code 92202 is: ‘Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral. Notes: (Do not report 92201, 92202 in conjunction with 92250)’

3. Procedure

1. The provider begins by administering dilating and numbing drops to the patient’s eye(s) to prepare for the examination.
2. After allowing time for the drops to take effect, the provider performs a direct ophthalmoscopy to assess the condition of the retina and posterior segment of the eye.
3. If the provider identifies any signs of serious retinal or posterior segment disease, they proceed with an extended ophthalmoscopy.
4. Using a headlamp or other bright light source and a hand-held indirect lens, the provider meticulously examines the interior of the eye, focusing on the optic nerve or macula.
5. During the examination, the provider may make one or more detailed drawings of the optic nerve or macula to document the extent of their findings.
6. After completing the examination, the provider interprets their findings and prepares a report that includes their impression and diagnosis.

4. Qualifying circumstances

CPT 92202 is typically performed when there is a need to evaluate conditions such as glaucoma, macular pathology, tumors, or other diseases affecting the optic nerve or macula. The procedure requires the provider to create a detailed drawing of the optic nerve or macula, documenting specific features such as optic cupping, disc rim, pallor, and optic slope. The drawing itself is not a report; the report must include findings and impressions, justifying the need for the extended ophthalmoscopy.

5. When to use CPT code 92202

CPT code 92202 should be used when the provider performs an extended ophthalmoscopy with drawing of the optic nerve or macula. It is important to note that this code should not be reported in conjunction with CPT codes 92201 or 92250.

6. Documentation requirements

To support a claim for CPT 92202, the provider must ensure the following documentation is included:

• Documentation of a condition considered medically necessary, which is typically identified during a routine ophthalmoscopy
• Detailed drawings of the optic nerve or macula, including standard colors and appropriate labels
• Date and time of the procedure
• Impressions and diagnosis justifying the extended ophthalmoscopy
• Any additional relevant information, such as changes in signs, symptoms, or condition

7. Billing guidelines

When billing for CPT 92202, it is important to follow the specific guidelines provided by the payer. Some carriers may bundle the payment for fundus photography into the payment for the extended ophthalmoscopy, while others may allow separate reporting of both procedures. It is recommended to check with the carrier to determine their specific requirements and whether modifiers are necessary.

8. Historical information

CPT 92202 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 patient presents with symptoms of glaucoma, and the provider performs an extended ophthalmoscopy to evaluate the optic nerve and macula, creating detailed drawings and preparing a report.
2. During a routine eye examination, the provider identifies signs of macular pathology and proceeds with an extended ophthalmoscopy, documenting the findings through drawings and interpreting the results.
3. A patient with a history of optic nerve tumors undergoes an extended ophthalmoscopy to assess the condition and create drawings for further evaluation and treatment planning.
4. Following a retinal detachment surgery, the provider performs an extended ophthalmoscopy to monitor the healing process and document any changes in the optic nerve or macula.
5. A patient with proliferative diabetic retinopathy requires regular extended ophthalmoscopy to evaluate the progression of the disease and guide treatment decisions.