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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellcare Hawaii Ophthalmoscopy Policy | OpenPayer
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    CurrentWellcare HawaiiPolicy CP.VP.26

    Extended Ophthalmoscopy

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    This policy governs medical necessity and documentation requirements for extended ophthalmoscopy performed to obtain and report a detailed examination of the posterior eye. It applies to providers and health plans affiliated with Centene Corporation, including Wellcare Hawaii.

    Policy Summary
    PayerWellcare Hawaii
    PolicyExtended Ophthalmoscopy
    Policy CodePolicy N/A
    Change TypeAdministrative/template revision
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a detailed, anatomically specific retinal or optic nerve/macula drawing with an interpretation and report.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    13Medically necessary indication categories
    3Not medically necessary situations
    2Referenced procedure codes
    3–4 inMinimum drawing diameter
    4Diabetes-related code families

    Coverage Criteria

    Medically Necessary Indications

    Covered as medically necessary when performed for one or more of the following indications:

    Indications

    • Covered indications

      • Infants undergoing treatment and/or monitoring of retinopathy of prematurity.
      • Histoplasmosis.
      • Choroidal neoplasms.
      • Glaucoma.
    Policy Summary
    PayerWellcare Hawaii
    PolicyExtended Ophthalmoscopy
    Policy CodePolicy N/A
    Change TypeAdministrative/template revision
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a detailed, anatomically specific retinal or optic nerve/macula drawing with an interpretation and report.
    SourceLink
    On This Page
    Coverage CriteriaCoding GuidanceProvider Documentation RequirementsClinical BackgroundKey Definitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Optic nerve pathology.
  1. Diabetic retinopathy.
  2. Hypertensive retinopathy.
  3. Vascular occlusion.
  4. Retinal neovascularization.
  5. Macular pathology.
  6. Retinal tear, thinning, schisis, or detachment.
  7. Hereditary retinal dystrophies.
  8. Other visible retinal disorders requiring detailed imaging for adequate documentation.

    9. Not Medically Necessary

    Not medically necessary under any of the following circumstances:

    Noncovered circumstances

    • Routine replacement of standard ophthalmoscopy with extended ophthalmoscopy to document the appearance of healthy retinal anatomy.
    • Duplicative documentation of retinal pathology when extended ophthalmoscopy is performed in conjunction with fundus photography, fluorescein angiography, or similar diagnostic procedures, unless the additional diagnostic procedures provide new information to assist in clinical decision-making.
    • Repeated performance in the presence of controlled and/or stable disease.

    Extended ophthalmoscopy is not medically necessary when standard ophthalmoscopy would adequately document healthy retinal anatomy.

    Extended ophthalmoscopy is not medically necessary when it duplicates retinal pathology documentation obtained through fundus photography, fluorescein angiography, or similar diagnostic procedures, unless the additional procedure provides new information to support clinical decision-making.

    Repeated performance of extended ophthalmoscopy is not medically necessary when the disease is controlled and/or stable.

    Noncovered utilization includes using extended ophthalmoscopy routinely instead of standard ophthalmoscopy to document healthy retinal anatomy, duplicating pathology documentation obtained through other diagnostic procedures without providing new clinical information, or repeatedly performing the service for controlled or stable disease.

    Extended ophthalmoscopy is not medically necessary for routine documentation of healthy retinal anatomy, duplicative documentation performed with fundus photography, fluorescein angiography, or similar procedures without new information for clinical decision-making, or repeated examination of controlled or stable disease.

    Coding Guidance

    Covered CPT CodesCPTCovered
    92201Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease, with interpretation and report, unilateral or bilateral
    92202Ophthalmoscopy, extended; with drawing of optic nerve or macula, with interpretation and report, unilateral or bilateral
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    A18.53; B39.5; B58.01; C69.21; C69.22; C69.31; C69.32; C69.41; C69.42; C72.31; C72.32; C72.59; D31.21; D31.22; D31.31; D31.32; D31.41; D31.42; D33.3Tuberculous, fungal, parasitic, malignant, benign, and other neoplasms involving the chorioretina, retina, choroid, ciliary body, optic nerve, and cranial nerves.
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    E08.3211; E08.3212; E08.3213; E08.3291; E08.3292; E08.3293; E08.3311; E08.3312; E08.3313; E08.3391; E08.3392; E08.3393; E08.3411; E08.3412; E08.3413; E08.3491; E08.3492; E08.3493; E08.3511; E08.3512; E08.3513; E08.3521; E08.3522; E08.3523; E08.3531; E08.3532; E08.3533; E08.3541; E08.3542; E08.3543; E08.3551; E08.3552; E08.3553; E08.3591; E08.3592; E08.3593Diabetes mellitus due to an underlying condition with diabetic retinopathy, including mild, moderate, severe, and proliferative disease with or without macular edema or retinal detachment, by eye.
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    E09.3211; E09.3212; E09.3213; E09.3291; E09.3292; E09.3293; E09.3311; E09.3312; E09.3313; E09.3391; E09.3392; E09.3393; E09.3411; E09.3412; E09.3413; E09.3491; E09.3492; E09.3493; E09.3511; E09.3512; E09.3513; E09.3521; E09.3522; E09.3523; E09.3531; E09.3532; E09.3533; E09.3541; E09.3542; E09.3543; E09.3551; E09.3552; E09.3553; E09.3591; E09.3592; E09.3593Drug or chemical induced diabetes mellitus with diabetic retinopathy, including nonproliferative and proliferative disease with macular edema, retinal detachment, or without macular edema, by eye.
    Drug or chemical induced diabetes mellitus with diabetic retinopathyICD-10
    E09.3211-E09.3593Drug or chemical induced diabetes mellitus with diabetic retinopathy; all listed laterality, severity, macular-edema, proliferative-retinopathy, and retinal-detachment variants.
    Type 1 diabetes mellitus with diabetic retinopathyICD-10
    E10.3211; E10.3212; E10.3213; E10.3291; E10.3292; E10.3293; E10.3311; E10.3312; E10.3313; E10.3391; E10.3392; E10.3393; E10.3411; E10.3412; E10.3413; E10.3491; E10.3492; E10.3493; E10.3511; E10.3512; E10.3513; E10.3521; E10.3522; E10.3523; E10.3531; E10.3532; E10.3533; E10.3541; E10.3542; E10.3543; E10.3551; E10.3552; E10.3553; E10.3591; E10.3592; E10.3593Type 1 diabetes mellitus with diabetic retinopathy, including nonproliferative and proliferative disease with or without macular edema or retinal detachment, by eye.
    Type 2 diabetes mellitus with diabetic retinopathyICD-10
    E11.3211; E11.3212; E11.3213; E11.3291; E11.3292; E11.3293; E11.3311; E11.3312; E11.3313; E11.3391; E11.3392; E11.3393; E11.3411; E11.3412; E11.3413; E11.3491; E11.3492; E11.3493; E11.3511; E11.3512; E11.3513; E11.3521; E11.3522; E11.3523; E11.3531; E11.3532; E11.3533; E11.3541; E11.3542; E11.3543; E11.3551; E11.3552; E11.3553; E11.3591; E11.3592; E11.3593Type 2 diabetes mellitus with diabetic retinopathy, including nonproliferative and proliferative disease with or without macular edema or retinal detachment, by eye.
    Other specified diabetes mellitus with diabetic retinopathyICD-10
    E13.3211; E13.3212; E13.3213; E13.3291; E13.3292; E13.3293; E13.3311; E13.3312; E13.3313; E13.3391; E13.3392; E13.3393; E13.3411; E13.3412; E13.3413; E13.3491; E13.3492; E13.3493; E13.3511; E13.3512; E13.3513; E13.3521; E13.3522; E13.3523; E13.3531; E13.3532; E13.3533; E13.3541; E13.3542; E13.3543; E13.3551; E13.3552; E13.3553; E13.3591; E13.3592; E13.3593Other specified diabetes mellitus with diabetic retinopathy, including nonproliferative and proliferative disease with or without macular edema or retinal detachment, by eye.
    Other ophthalmic diagnosesICD-10
    G45.3; H15.031; H15.032; H15.033; H16.241; H16.242; H16.243; H20.821; H20.822; H20.823; H21.331; H21.332; H21.333; H27.111; H27.112; H27.113; H27.131; H27.132; H27.133Amaurosis fugax, posterior scleritis, ophthalmia nodosa, Vogt-Koyanagi syndrome, parasitic cysts, and lens subluxation or dislocation.
    ICD-10-CM ophthalmic diagnosis codesICD-10
    H30.011-H35.82; H40.011-H40.833; H43.01-H44.823; H46.01-H47.49; H53.121-H59.033; Q14.0-Q15.0; Q85.1; Q85.8; Q85.9; Q87.42; S05.11XA-T85.22XSChorioretinal, retinal, glaucoma, vitreous, globe, optic nerve, visual-loss, congenital, hereditary, traumatic, and intraocular-lens diagnoses listed in the policy.
    ICD-10-CM chorioretinal, choroidal, and macular diagnosis codesICD-10
    H30.011; H30.012; H30.013; H30.021; H30.022; H30.023; H30.031; H30.032; H30.033; H30.041; H30.042; H30.043; H30.111; H30.112; H30.113; H30.121; H30.122; H30.123; H30.131; H30.132; H30.133; H30.141; H30.142; H30.143; H30.21; H30.22; H30.23; H30.811; H30.812; H30.813; H31.011; H31.012; H31.013; H31.021; H31.022; H31.023; H31.101; H31.102; H31.103; H31.111; H31.112; H31.113; H31.121; H31.122; H31.123; H31.21; H31.22; H31.23; H31.311; H31.312; H31.313; H31.321; H31.322; H31.323; H35.3111-H35.383Chorioretinal inflammation, cyclitis, Harada disease, choroidal atrophy and degeneration, choroidal hemorrhage or rupture, and macular disorders.
    ICD-10-CM choroidal and retinal detachment diagnosis codesICD-10
    H31.411; H31.412; H31.413; H31.421; H31.422; H31.423; H33.011; H33.012; H33.013; H33.021; H33.022; H33.023; H33.031; H33.032; H33.033; H33.041; H33.042; H33.043; H33.051; H33.052; H33.053; H33.111; H33.112; H33.113; H33.121; H33.122; H33.123; H33.21; H33.22; H33.23; H33.311-H33.43; H44.2C1; H44.2C2; H44.2C3Choroidal detachment, retinal detachment, retinal cysts, retinal tears, retinal holes, and traction detachment diagnoses.
    ICD-10-CM retinal tear, vascular, and retinopathy diagnosis codesICD-10
    H33.311; H33.312; H33.313; H33.321; H33.322; H33.323; H33.331; H33.332; H33.333; H34.01-H34.8332; H35.011-H35.173Retinal tears, holes, retinal vascular occlusions, venous occlusions, vascular changes, exudative and hypertensive retinopathy, retinal microaneurysms, vasculitis, telangiectasis, and retinopathy of prematurity.
    ICD-10-CM retinopathy, macular degeneration, and macular disorder codesICD-10
    H35.3111-H35.383; H35.51; H35.52; H35.54Age-related macular degeneration, angioid streaks, macular cyst or hole, cystoid macular degeneration, drusen, macular pucker, toxic maculopathy, and vitreoretinal or pigmentary dystrophies.
    ICD-10-CM retinal degeneration, hemorrhage, and retinal pigment epithelium codesICD-10
    H35.411-H35.463; H35.61; H35.62; H35.63; H35.711; H35.712; H35.713; H35.721; H35.722; H35.723; H35.731; H35.732; H35.733; H35.81; H35.82Retinal degeneration, hemorrhage, central serous chorioretinopathy, serous or hemorrhagic detachment of retinal pigment epithelium, retinal edema, and retinal ischemia.
    ICD-10-CM diagnosis codesICD-10Covered
    H40.011-H40.833; H43.01-H44.823; H46.01-H47.49; H53.121-H59.033; Q14.0-Q15.0; Q85.1; Q85.8; Q85.9; Q87.42; S05.11XA; S05.11XD; S05.11XS; S05.12XA; S05.12XD; S05.12XS; S05.21XA; S05.21XD; S05.21XS; S05.22XA; S05.22XD; S05.22XS; S05.31XA; S05.31XD; S05.31XS; S05.32XA; S05.32XD; S05.32XS; S05.51XA; S05.51XD; S05.51XS; S05.52XA; S05.52XD; S05.52XS; S05.61XA; S05.61XD; S05.61XS; S05.62XA; S05.62XD; S05.62XS; S05.71XA; S05.71XD; S05.71XS; S05.72XA; S05.72XD; S05.72XS; T85.22XA; T85.22XD; T85.22XSGlaucoma, vitreous, globe, optic nerve, visual-loss, congenital, hereditary, traumatic, and intraocular-lens diagnoses listed as covered in the policy.
    ICD-10 diagnosis codesICD-10
    H40.011-H40.833; H43.01-H44.823; H46.01-H47.49; H53.121-H59.033; Q14.0-Q15.0; Q85.1; Q85.8; Q85.9; Q87.42; S05.11XA-T85.22XSAdditional ophthalmic, congenital, hereditary, traumatic, and postoperative diagnosis codes referenced in the policy.
    Documentation Requirement
    Detailed retinal drawing diameterMinimum 3–4 inches in diameter

    Provider Documentation Requirements

    Documentation Required

    Required Extended Ophthalmoscopy Report and Drawing

    When extended ophthalmoscopy is performed, the provider must create a detailed retinal drawing of the disc, macula, or periphery, accompanied by an interpretation and report. The drawing must accurately represent the patient’s normal and abnormal findings, including relevant retinal pathology.

    • Include views of one or both eyes, as clinically applicable, after routine ophthalmoscopy when a more detailed examination—including the periphery—is needed.
    • Use an anatomically specific drawing that is clearly labeled and at least 3–4 inches in diameter.
    • Accurately depict findings such as lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, retinal detachments, holes, tears, or tumors.
    • When documenting optic nerve changes, include ancillary cup-to-disc data: size, depth, rim, vessels, and coloration.
    Denial Risk

    Noncovered Utilization Patterns

    Extended ophthalmoscopy is not medically necessary when it is used as a routine substitute for standard ophthalmoscopy or when it does not add clinically meaningful information. Avoid repeating the service for controlled or stable disease unless a new clinical need is documented.

    • Do not use extended ophthalmoscopy solely to document the appearance of healthy retinal anatomy.
    • Do not duplicate retinal pathology documentation with fundus photography, fluorescein angiography, or similar diagnostic procedures unless the additional procedure provides new information that supports clinical decision-making.
    • Repeated performance in the presence of controlled and/or stable disease is noncovered.
    Denial Risk

    Insufficient or Duplicative Documentation

    Claims may be denied when the record lacks an anatomically specific, clearly labeled retinal drawing of sufficient size, together with the required interpretation and report. Documentation is also insufficient when extended ophthalmoscopy merely duplicates other services or when its findings are used to satisfy documentation requirements for another service.

    • A generic, unlabeled, undersized, or non-patient-specific drawing does not support the service; the drawing must be at least 3–4 inches in diameter and accurately depict the documented findings.
    • The interpretation and report must accompany the drawing; a drawing alone is insufficient.
    • Fundus examination elements—disc, macula, vessels, and periphery—cannot simultaneously satisfy documentation requirements for evaluation and management (E&M) or other eye services and extended ophthalmoscopy.
    • For optic nerve changes, omission of ancillary cup-to-disc details—size, depth, rim, vessels, and coloration—creates documentation risk.

    Clinical Background

    Extended ophthalmoscopy is used when a more detailed examination of the posterior eye, including the retinal periphery, is needed after routine ophthalmoscopy. It is generally performed after pupil dilation and may use direct or indirect ophthalmoscopy, contact lens biomicroscopy, or scleral depression. The examination allows visualization of the optic disc, macula, retinal arteries and veins, retina, choroid, vitreous, and media, and requires a detailed drawing with an interpretation and report.

    Key Definitions

    Extended ophthalmoscopy
    Examination methodA method of examining the posterior portion of the eye when the level of examination requires a complete view of the back of the eye and documentation is greater than that required during routine ophthalmoscopy.
    Detailed retinal drawing
    DefinitionA detailed, anatomically specific drawing of the patient's retina or optic nerve/macula, accompanied by an interpretation and report.
    Required viewsDisc, macula, or periphery, as applicable.
    Labeling and accuracyThe drawing must be anatomically specific to the patient, clearly labeled, and accurately represent normal, abnormal, and common findings.
    Optic nerve changesAncillary cup-to-disc drawings must document size, depth, rim, vessels, and coloration.