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CPT 92201: Extended Ophthalmoscopy With Retinal Drawing
CPT code 92201 represents an extended ophthalmoscopy using an indirect ophthalmoscope, often with scleral depression, combined with a retinal drawing and written interpretation. This code captures comprehensive posterior segment evaluation beyond a standard ophthalmoscopic exam and is used when detailed documentation of peripheral retinal findings is required. Nationally, accurate reporting of 92201 matters for clinical documentation, continuity of care in ophthalmology, and claims processing for specialty diagnostic eye services.
Key payers covered in typical analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical intent of the code, typical sites where the service is delivered, and the scope of documentation expected for an extended indirect ophthalmoscopy with retinal drawing.
This publication provides benchmarks and coding context for 92201, highlights clinical scenarios where the procedure is applicable, and summarizes common billing considerations and reporting practices. It also outlines where to find related service codes and what elements of the examination should be documented to support billing. Data not available in the input is noted where applicable.
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Billing Code Overview
CPT code 92201 describes an extended ophthalmoscopy performed with an indirect ophthalmoscope and typically includes scleral depression to visualize the posterior segment and peripheral fundus. The procedure requires creating a retinal drawing with interpretation and producing a written report. Report this code for an extended ophthalmoscopy with retinal drawing on one or both eyes.
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Service type: Diagnostic ophthalmologic examination focused on detailed retinal and posterior segment evaluation
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Typical site of service: Eye clinic or ophthalmology office setting, ambulatory surgical center, or other outpatient ophthalmic specialty facility