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Title of Medical Policy

Ophthalmoscopy: Extended

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Oxford Medicare Advantage Members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

Coverage Statement

Policy is applicable to:

    Commercial plans

    Oxford Medicare Advantage® plans, including Medicare Group Accounts (MGA)

Conditions of Coverage
Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
Yes1
Authorization (Precertification always required for inpatient admission) No
Precertification with MD Review No
Site(s) of Service
(If not listed, MD Review required)
Office
Special Considerations A referral is not required for CPT Codes 92225 or 92226 when supported by a diagnosis of 250-250.93, 357.2, 362.0, 366.41, or 765.xx. In addition, any other services performed with any of the CPT Codes listed above are valid without a referral if the additional services do not require precertification.

Description of Service, Assessment, and Background Information

Ophthalmoscopy is an examination of the posterior portion of the eye: aperture, iris, crystalline lens vitreous, retina and optic disc. It may be performed with a standard hand held ophthalmoscope (direct ophthalmoscopy).

Extended Ophthalmoscopy is a method of examination of the posterior portion of the eye. It is usually performed with the pupil dilated, using indirect ophthalmoscopic techniques - hand held condensing lens with separate and distinct light source - and may include scleral depression. A retinal drawing is included as part of the service. Accepted documentation should include international color-coding of anatomy and pathology and a clearly worded description of pathology.

Policy and Rationale

Routine ophthalmoscopy (Direct or Indirect) is covered as an integral part of a general ophthalmologic examination.

Extended Ophthalmoscopy with retinal drawing (Non-routine Ophthalmoscopy) is covered for diagnosis of retinal and associated disorders only. (Including the retina, vessels, choroid, vitreous, and optic nerve.)

  • Oxford Health Plans provides coverage for extended ophthalmoscopy with appropriately sized retinal drawing with international system of color-coding where indicated---when supported by diagnosis. (See table)
    • Initial evaluation may be used if that physician or group of physicians has not evaluated the patient in 3 or more years.
    • Subsequent evaluation is used when that physician or group of physicians has evaluated the patient within 3 years.
Criteria for Coverage
N/A

Additional Guidelines
N/A

Required Documentation

N/A

Applicable ICD-9 Codes

Extended (Non-Routine) Ophthalmoscopy (92225, 92226) is covered for the following diagnoses only:

ICD-9 Codes Description
017.3 Tuberculosis of the eye
091.5 Uveitis due to secondary syphilis
091.50 Syphilitic uveitis, unspecified
091.51 Syphilitic chorioretinitis (secondary)
091.52 Syphilitic iridocyclitis (secondary)
094.83 Syphilitic disseminated retinochoroiditis
094.84 Syphilitic optic atrophy
094.85 Syphilitic retrobulbar neuritis
098.41 Gonococcal iridocyclitis
098.42 Gonococcal endophthalmia
115.02 Histoplasmosis, retinal
115.12 Histoplasmosis, retinal
115.92 Histoplasmosis, retinal
130.2 Chorioretinitis due to toxoplasmosis
135 Sarcoidosis
190.0 Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
190.5 Malignant neoplasm of the eye, retina
190.6 Malignant neoplasm of the eye, choroid
224.5 Benign neoplasm of eye, retina
224.6 Benign neoplasm of eye, choroid
225.1 Benign neoplasm of cranial nerves
228.03 Hemangioma and lymphangioma of retina
237.70-237.72 Neurofibromatosis
250-250.93 Diabetes with ophthalmic manifestations
360.0 Purulent endophthalmitis
360.00 Purulent endophthalmitis, unspecified
360.01 Acute endophthalmitis
360.02 Panophthalmitis
360.03 Chronic endophthalmitis
360.04 Vitreous abscess
360.1 Other endophthalmitis
360.11 Sympathetic uveitis
360.12 Panuveitis
360.13 Parasitic endophthalmitis NOS
360.14 Ophthalmia nodosa
360.19 Other; Phacoanaphylactic endophthalmitis
360.20 Degenerative disorder of globe, unspecified
360.21 Progressive high (degenerative) myopia
360.23 Siderosis
360.24 Other metallosis
360.29 Other
360.3 Hypotony of eye
360.30 Hypotony, unspecified
360.31 Primary hypotony
360.32 Ocular fistula causing hypotony
360.33 Hypotony associated with other ocular disorders
360.34 Flat anterior chamber
360.40-360.44 Degenerated conditions of globe
360.5 Retained (old) intraocular foreign body, magnetic
360.50 Foreign body, magnetic, intraocular, unspecified
360.51 Foreign body, magnetic, in anterior chamber
360.52 Foreign body, magnetic, in iris or ciliary body
360.53 Foreign body, magnetic in lens
360.54 Foreign body, magnetic, in vitreous
360.55 Foreign body, magnetic in posterior wall
360.59 Foreign body, magnetic, in other or multiple sites
360.6 Retained (old) intraocular foreign body, nonmagnetic
360.60 Foreign body, intraocular, unspecified
360.61 Foreign body, in anterior chamber
360.62 Foreign body in iris or ciliary body
360.63 Foreign body in lens
360.64 Foreign body in vitreous
360.65 Foreign body in posterior wall
360.69 Foreign body in other or multiple sites
360.81-360.89 Other disorders of globe
360.9 Unspecified disorder of globe
361 Retinal detachments and defects
361.0 Retinal detachment with retinal defect
361.00 Retinal detachment with retinal defect, unspecified
361.01 Recent detachment, partial, with single defect
361.02 Recent detachment, partial, with multiple defects
361.03 Recent detachment, partial, with giant tear
361.04 Recent detachment, partial, with retinal dialysis
361.05 Recent detachment, total or subtotal
361.06 Old detachment, partial
361.07 Old detachment, total or subtotal
361.1 Retinoschisis and retinal cysts
361.10 Retinoschisis, unspecified
361.11 Flat retinoschisis
361.12 Bullous retinoschisis
361.13 Primary retinal cysts
361.14 Secondary retinal cysts
361.19 Other
361.2 Serous retinal detachment
361.3 Retinal defects without detachment
361.30 Retinal defect, unspecified
361.31 Round hole of retina without detachment
361.32 Horseshoe tear of retina without detachment
361.33 Multiple defects of retina without detachment
361.8-361.89 Other forms of retinal detachment
361.9 Unspecified retinal detachment
362 Other retinal disorders
362.0 Diabetic retinopathy
362.01 Background diabetic retinopathy
362.02 Proliferative diabetic retinopathy
362.1 Other background retinopathy and retinal vascular changes
362.10 Background retinopathy, unspecified
362.11 Hypertensive retinopathy
362.12 Exudative retinpathy
362.13 Changes in vascular appearance
362.14 Retinal microaneurysms NOS
362.15 Retinal telangiectasia
362.16 Retinal neovascularization NOS
362.17 Other intraretinal microvascular abnormalities
362.18 Retinal vasculitis
362.2 Other proliferative retinopathy
362.21 Retrolental fibroplasia
362.29 Other nondiabetic proliferative retinopathy
362.3 Retinal vascular occlusion
362.30 Retinal vascular occlusion, unspecified
362.31 Central retinal artery occlusion
362.32 Arterial branch occlusion
362.33 Partial arterial occlusion
362.34 Transient arterial occlusion
362.35 Central retinal vein occlusion
362.36 Venous tributary (branch) occlusion
362.37 Venous engorgement
362.4 Separation of retinal layers
362.40 Retinal layer separation, unspecified
362.41 Central serous retinopathy
362.42 Serous detachment of retinal pigment epithelium
362.43 Hemorrhagic detachment
362.5 Degeneration of macula and posterior pole
362.50 Macular degeneration (senile) unspecified
362.51 Nonexudative senile macular degeneration
362.52 Exudative senile macular degeneration
362.53 Cystiod macular degeneration
362.54 Macular cyst, hole, or pseudohole
362.55 Toxic maculopathy
362.56 Macular puckering
362.57 Drusen (degenerative)
362.60-362.66 Peripheral retinal degenerations
362.70-362.77 Heredity retinal dystrophies
362.8 Other retinal disorders
362.81 Retinal hemorrhage
362.82 Retinal exudates and deposits
362.83 Retinal edema
362.84 Retinal ischemia
362.85 Retinal nerve fiber bundle defects
362.89 Other retinal disorders
362.9 Unspecified retinal disorder
363 Chorioretinal inflammations, scars, and other disorders of choroid
363.0 Focal chorioretinitis and focal retinochoroiditis
363.00 Focal chorioretinitis, unspecified
363.01 Focal choroiditis and chorioretinitis, juxtapapillary
363.03 Focal choroiditis and chorioretinitis of other posterior pole
363.04 Focal choroiditis and chorioretinitis, peripheral
363.05 Focal retinitis and retinochoroiditis, juxtapapillary
363.06 Rocal retinitis and retinochoroiditis, macular or paramacular
363.07 Focal retinitis and retinochoroiditis of other posterior pole
363.08 Focal retinitis and retinochoroiditis, peripheral
363.1 Disseminated chorioretinitis and desseminated retinochoroiditis
363.10 Disseminated chorioretinitis, unspecified
363.11 Disseminated chorioditis and chorioretinits, posterior pole
363.12 Disseminated choroiditis and chorioretinits, peripheral
363.13 Disseminated choroiditis and chorioretinits, generalized
363.14 Disseminated retinitis and retinochorioditis, metastatic
363.15 Disseminated retinitis and retinochorioditis, pigment
363.2 Other and unspecified forms of retinitis and retinochorioditis
363.20 Chorioretinits, unspecified
363.21 Par planitis
363.22 Harada's disease
363.3 Chorioretinal scars
363.30 Chorioretinal scar, unspecified
363.31 Solar retinopathy
363.32 Other macular scars
363.33 Other scars of posterior pole
363.34 Peripheral scars
363.35 Disseminated scars
363.4 Choroidal degenerations
363.40 Choroidal degeneration, unspecified
363.41 Senile atrophy of choroid
363.42 Diffuse secondary atrophy of choroid
363.43 Angioid streaks of choroid
363.5 Hereditary choroidal dystrophies
363.50 Hereditary choroidal dystrophy or atrophy, unspecified
363.51 Circumpapillary dystrophy of choroid, partial
363.52 Circumpapillary dystrophy of choroid, total
363.53 Central dystrophy of choroid, partial
363.54 Central choroidal atrophy, total
363.55 Choroideremia
363.56 Other diffuse or generalized dystrophy, partial
363.57 Other diffuse or generalized dystrophy, total
363.6 Choroidal hemorrhage and rupture
363.61 Choroidal hemorrhage, unspecified
363.62 Expulsive choroidal hemorrhage
363.63 Choroidal rupture
363.7 Choroidal detachment
363.70 Choroidal detachment, unspecified
363.71 Serous choroidal detachment
363.72 Hemorrhagic choroidal detachment
363.8 Other disorders of choroid
363.9 Unspecified disorder of choroid
364.00-364.04 Acute and subacute Iridocyclitis
364.10-364.11 Chronic iridocyclitis
364.21-364.24 Other types of iridocyclitis
364.3 Unspecified iridocyclitis
364.41-364.42 Vascular disorders of iris and ciliary body
364.51-364.59 Degenerations of iris and ciliary body
364.60-364.64 Cysts of iris, ciliary body and anterior chamber
364.70-364.77 Adhesions and disruptions of iris and ciliary body
364.8-364.9 Other and unspecified disorders of iris and ciliary body
365.00-365.04 Borderline glaucoma (glaucoma suspect)
365.10-365.15 Open-angle glaucoma
365.20-365.24 Primary angle-closure glaucoma
365.31-365.32 Corticosteroid-induced glaucoma
365.41-365.44 Glaucoma associated with congenital anomalies, dystrophies, and systemic syndromes
365.51-365.59 Glaucoma associated with disorders of the lens
365.60-365.65 Glaucoma associated with other ocular disorders
365.81-365.89 Other specified forms of glaucoma
365.9 Unspecified glaucoma
366.41 Cataract associated with diabetes
368.10 Subjective visual disturbance, unspecified
368.11 Sudden visual loss
368.12 Transient visual loss
368.14 Visual distortions of shape and size
368.15 Other visual distortions and entoptic phenomena
368.16 Psychophysical visual disturbances
368.4 Visual field defects
368.40 Visual field defect, unspecified
368.41 Scotoma involving central area
368.42 Scotoma of blind spot area
368.43 Sector or arcuate defects
368.44 Other localized visual field defect
368.45 Generalized contraction or constriction
368.46 Homonymous bilateral field defects
368.47 Heteronymous bilateral field defects
368.60-368.69 Night blindness
368.8-368.9 Other and unspecified visual disturbances
369.00-369.08 Profound impairment, both eyes
369.9 Unspecified visual loss
376.40-376.47 Deformity of orbit
376.50-376.52 Enophthalmos
376.6 Retained (old) foreign body following penetrating wound of orbit
377 Disorders of optic nervie and visual pathways
377.0 Papilledema
377.00 Papilledema, unspecified
377.01 Papilledema associated with increased intracranial pressure
377.02 Papilledema associated with decreased ocular pressure
377.03 Papilledema associated with retinal disorder
377.04 Foster-Kennedy syndrome
377.1 Optic atrophy
377.10 Optic atrophy, unspecified
377.11 Primary optic atrophy
377.12 Postinflammatory optic atrophy
377.13 Optic atrophy associated with retinal dystrophies
377.14 Galucomatous atrophy (cupping) of optic disc
377.15 Partial optic atrophy
377.16 Hereditary optic atrophy
377.2 Other disorders of optic disc
377.21 Drusen of optic disc
377.22 Crater-like holes of optic disc
377.23 Coloboma of optic disc
377.24 Pseudopapilledema
377.3 Optic neuritis
377.30 Optic neuritis, unspecified
377.31 Optic papillitis
377.32 Retrobulbar neuritis (acute
377.33 Nutritional optic neuropathy
377.34 Toxic optic neuropathy
377.39 Other
377.4 Other disorders of optic nerve
377.41 Ischemic optic neuropathy
377.42 Hemorrhage in optic nerve sheaths
377.49 Other
377.5 Disorders of optic chiasm
377.51 Associated with pituitary neoplasms and disorders
377.52 Associated with other neoplasms
377.53 Associated with vascular disorders
377.54 Associated with inflammatory disorders
377.6 Disorders of other visual pathways
377.61 Associated with neoplasms
377.62 Associated with vascular disorders
377.63 Associated with inflammatory disorders
377.7 Disorders of visual cortex
377.71 Associated with neoplasms
377.72 Associated with vascular disorders
377.73 Associated with inflammatory disorders
377.75 Cortical blindness
377.9 Unspecified disorder of optic nerve and visual pathways
379.07 Posterior scleritis
379.09 Other
379.11 Scleral ectasia
379.12 Staphyloma posticum
379.13 Equatorial staphyloma
379.14 Anterior staphyloma, localized
379.15 Ring staphyloma
379.16 Other
379.19 Other
379.21 Vitreous degeneration
379.22 Crystalline deposits in vitreous
379.23 Vitreous hemorrhage
379.24 Other vitreous opacities
379.25 Vitreous membranes and strands
379.26 Vitreous prolapse
379.29 Other disorders of vitreous
379.32 Subluxation of lens
379.34 Posterior location of lens
446.5 Giant cell arteritis
714.0 Rheumatoid Arthritis
714.30-714.33 Juvenile chronic polyarthritis
743.5 Congential anomalies of posterior segment
743.51 Vitreous anomalies
743.52 Fundus coloboma
743.53 Chorioretinal degeneration, congenital
743.54 Congential folds and cysts of posterior segment
743.55 Congenital macular changes
743.56 Other retinal changes, congenital
743.57 Specified anomalies of optic disc
743.58 Vascular anomalies
743.59 Other congenital anomalies of posterior segment
759.5 Tuberous scleoris
759.6 Other hamartoses, not elsewhere classified
759.82 Marfan syndrome
765.xx Extreme immaturity
871.5-871.9 Penetration of eyeball with foreign body (magnetic, nonmagnetic
921 Contusion of eye and adnexa
921.3 Contusion of eyeball
921.9 Unspecified
958.1 Fat embolism as an early complication of trauma
995.50-995.59 Child maltreatment syndrome
V58.69 Long term (current) use of other medications, high risk medications
V67.51 Follow-up examination; completed treatment with high-risk medication, not elsewhere classified

Applicable CPT Codes

CPT Codes Description
92225 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial.
92226 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; subsequent

References

  1. Empire Medicare Services – New York. “Extended Ophthalmoscopy.” Policy number OP006E01. Effective January 1, 2003. Retrieved September 5, 2003.
  2. Empire Medicare Services - New Jersey. "Ophthalmoscopy, Extended". Policy number M-44C. Effective October 1, 2002. Retrieved September 5, 2003.
  3. Medicare Legal Review. September 24, 2003.
# VISION 010.2 T0
Effective Date: January 1, 2005