CurrentWellCarePolicy CP.VP.26

Extended ophthalmoscopy

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Medical necessity criteria and coding guidance for extended ophthalmoscopy examinations of the posterior eye, governing coverage decisions for providers and claims reviewers for WellCare (Centene/Envolve) health plans.

Policy Summary

PayerWellCare

PolicyExtended ophthalmoscopy

Policy CodePolicy CP.VP.26

Change TypeAnnual review (no material changes)

Effective DateN/A

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionWhen billing, use CPT codes 92201 or 92202 and document an anatomically specific retinal drawing with interpretation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13Indications listed

3Not medically necessary items

2Covered CPT codes

20+ICD-10 codes (partial)

01/2020Original approval

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CurrentWellCarePolicy CP.VP.26

Extended ophthalmoscopy

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Policy Summary

PayerWellCare

PolicyExtended ophthalmoscopy

Policy CodePolicy CP.VP.26

Change TypeAnnual review (no material changes)

Effective DateN/A

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionWhen billing, use CPT codes 92201 or 92202 and document an anatomically specific retinal drawing with interpretation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13Indications listed

3Not medically necessary items

2Covered CPT codes

20+ICD-10 codes (partial)

01/2020Original approval

Coverage Criteria

Medically Necessary Indications

Covered when any of the following indications are present:

Indications for medical necessity: A. Infants undergoing treatment and/or monitoring of retinopathy of prematurity; B. Histoplasmosis; C. Choroidal neoplasms; D. Glaucoma; E. Optic nerve pathology; F. Diabetic retinopathy; G. Hypertensive retinopathy; H. Vascular occlusion; I. Retinal neovascularization; J. Macular pathology; K. Retinal tear, thinning, schisis or detachment; L. Hereditary retinal dystrophies; M. Other visible retinal disorders requiring detailed imaging for adequate documentation.

Each listed indication alone supports medical necessity when documented.

Not Medically Necessary

Not medically necessary in the following situations:

Not medically necessary situations: A. Routine replacement of standard ophthalmoscopy with extended ophthalmoscopy to document the appearance of healthy retinal anatomy; B. Duplicative documentation of retinal pathology with extended ophthalmoscopy in conjunction with fundus photography, fluorescein angiography, etc., unless the additional diagnostic procedures provide new information to assist in clinical decision-making; C. Repeated performance in the presence of controlled and/or stable disease.

These conditions indicate lack of medical necessity.

Claims for extended ophthalmoscopy may be denied when the service is used as a routine replacement of standard ophthalmoscopy, when it is duplicative of other retinal imaging (for example, fundus photography or fluorescein angiography) without providing new diagnostic information, or when the procedure is repeated for controlled or stable disease. Documentation should clearly show why extended ophthalmoscopy provided additional clinical value beyond routine exam or other imaging and must support the specific indication that meets medical necessity criteria.

This clinical policy is intended as a guide to medical necessity and does not guarantee payment. Coverage and payment are determined by the member's plan documents and are subject to all applicable terms, conditions, exclusions, and limitations, as well as state and federal requirements and Health Plan-level administrative procedures. Providers should verify benefits and any plan-level rules before submitting claims.

Extended ophthalmoscopy is not medically necessary when performed as a routine substitute for standard ophthalmoscopy to document healthy retinal appearance, when it merely duplicates documentation available from other imaging modalities without adding new clinically relevant information, or when it is repeatedly performed for patients with controlled or stable disease. Billing and medical records should reflect that the extended exam was required to evaluate or manage a qualifying retinal or posterior segment condition listed in the policy.

Coding

Covered CPT CodesCPTCovered

92201	Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.
92202	Ophthalmoscopy, extended; with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.

Example ICD-10 Codes Supporting Coverage (partial list)ICD-10

A18.53	Tuberculous chorioretinitis
A18.54	Tuberculous iridocyclitis
B39.4	Histoplasmosis capsulati, unspecified
B39.5	Histoplasmosis duboisii
B58.01	Toxoplasma chorioretinitis
C69.21	Malignant neoplasm of right retina
C69.22	Malignant neoplasm of left retina
C69.31	Malignant neoplasm of right choroid
C69.32	Malignant neoplasm of left choroid
C69.41	Malignant neoplasm of right ciliary body

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Diabetes-related retinopathy ICD-10 codes (partial list)ICD-10

E10.3292	Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293	Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3312	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E10.3313	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3392	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393	Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3412	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3492	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493	Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

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Continuing diabetes-related retinopathy ICD-10 codes (partial)ICD-10

E11.3392	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3411	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3491	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3512	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

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Posterior segment / retinal ICD-10 codes (partial list)ICD-10

H15.031	Posterior scleritis, right eye
H15.032	Posterior scleritis, left eye
H15.033	Posterior scleritis, bilateral
H16.241	Posterior scleritis, bilateral
H16.242	Ophthalmia nodosa, right eye
H16.243	Ophthalmia nodosa, bilateral
H20.011	Primary iridocyclitis, right eye
H20.012	Primary iridocyclitis, left eye
H20.013	Primary iridocyclitis, bilateral
H20.021	Recurrent acute iridocyclitis, right eye

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ICD-10 Diagnosis Codes cited in policy excerptICD-10

H31.22	Choroideremia
H31.23	Choroidal dystrophy (central areolar) (generalized) (peripapillary)
H31.311	Expulsive choroidal hemorrhage, right eye
H31.312	Expulsive choroidal hemorrhage, left eye
H31.313	Expulsive choroidal hemorrhage, bilateral
H31.321	Choroidal rupture, right eye
H31.322	Choroidal rupture, left eye
H31.323	Choroidal rupture, bilateral
H31.411	Hemorrhagic choroidal detachment, right eye
H31.412	Hemorrhagic choroidal detachment, left eye

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Glaucoma-related ICD-10 codes (partial)ICD-10

H40.33X2	Glaucoma secondary to eye trauma, bilateral, moderate stage
H40.33X3	Glaucoma secondary to eye trauma, bilateral, severe stage
H40.41X1	Glaucoma secondary to eye inflammation, right eye, mild stage
H40.41X2	Glaucoma secondary to eye inflammation, right eye, moderate stage
H40.41X3	Glaucoma secondary to eye inflammation, right eye, severe stage
H40.42X1	Glaucoma secondary to eye inflammation, right eye, severe stage (entry wording inconsistent in excerpt)
H40.42X2	Glaucoma secondary to eye inflammation, left eye, mild stage
H40.42X3	Glaucoma secondary to eye inflammation, left eye, moderate stage

Additional glaucoma ICD-10 codes (partial)ICD-10

H40.43X1	Glaucoma secondary to eye inflammation, bilateral, mild stage
H40.43X2	Glaucoma secondary to eye inflammation, bilateral, moderate stage
H40.43X3	Glaucoma secondary to eye inflammation, bilateral, severe stage
H40.51X1	Glaucoma secondary to other eye disorders, right eye, mild stage
H40.51X2	Glaucoma secondary to other eye disorders, right eye, moderate stage
H40.51X3	Glaucoma secondary to other eye disorders, right eye, severe stage
H40.52X1	Glaucoma secondary to other eye disorders, left eye, mild stage
H40.52X2	Glaucoma secondary to other eye disorders, left eye, moderate stage
H40.52X3	Glaucoma secondary to other eye disorders, left eye, severe stage
H40.53X1	Glaucoma secondary to other eye disorders, bilateral, mild stage

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Vitreous and related ICD-10 codes (partial)ICD-10

H40.811	Glaucoma with increased episcleral venous pressure, right eye
H40.812	Glaucoma with increased episcleral venous pressure, left eye
H40.813	Glaucoma with increased episcleral venous pressure, bilateral
H40.821	Hypersecretion glaucoma, right eye
H40.822	Hypersecretion glaucoma, left eye
H40.823	Hypersecretion glaucoma, bilateral
H40.831	Aqueous misdirection, right eye
H40.832	Aqueous misdirection, left eye
H40.833	Aqueous misdirection, bilateral
H43.01	Vitreous prolapse, right eye

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More vitreous/retina ICD-10 codes (partial)ICD-10

H43.21	Crystalline deposits in vitreous body, right eye
H43.22	Crystalline deposits in vitreous body, left eye
H43.23	Crystalline deposits in vitreous body, bilateral
H43.311	Vitreous membranes and strands, right eye
H43.312	Vitreous membranes and strands, left eye
H43.313	Vitreous membranes and strands, bilateral
H43.811	Vitreous membranes and strands, bilateral (duplicate/formatting in excerpt)
H43.812	Vitreous degeneration, left eye
H43.813	Vitreous degeneration, bilateral
H43.821	Vitreomacular adhesion, right eye

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Endophthalmitis/panuveitis ICD-10 codes (partial)ICD-10

H44.001	Unspecified purulent endophthalmitis, right eye
H44.002	Unspecified purulent endophthalmitis, left eye
H44.003	Unspecified purulent endophthalmitis, bilateral
H44.011	Panophthalmitis (acute), right eye
H44.012	Panophthalmitis (acute), left eye
H44.013	Panophthalmitis (acute), bilateral
H44.021	Vitreous abscess (chronic), right eye
H44.022	Vitreous abscess (chronic), left eye
H44.023	Vitreous abscess (chronic), bilateral
H44.111	Panuveitis, right eye

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Uveitis, degenerative myopia codes (partial)ICD-10

H44.121	Panuveitis, bilateral (formatting in excerpt)
H44.131	Parasitic endophthalmitis, unspecified, right eye
H44.132	Parasitic endophthalmitis, unspecified, left eye
H44.133	Parasitic endophthalmitis, unspecified, bilateral
H44.21	Sympathetic uveitis, right eye
H44.22	Sympathetic uveitis, left eye
H44.23	Sympathetic uveitis, bilateral
H44.2A1	Degenerative myopia with choroidal neovascularization, right eye
H44.2A2	Degenerative myopia with choroidal neovascularization, left eye
H44.2A3	Degenerative myopia with choroidal neovascularization, bilateral

Degenerative myopia subgroup (partial)ICD-10

H44.2B1	Degenerative myopia with macular hole, right eye
H44.2B2	Degenerative myopia with macular hole, left eye
H44.2B3	Degenerative myopia with macular hole, bilateral
H44.2C1	Degenerative myopia with retinal detachment, right eye
H44.2C2	Degenerative myopia with retinal detachment, left eye
H44.2C3	Degenerative myopia with retinal detachment, bilateral
H44.2D1	Degenerative myopia with foveoschisis, right eye
H44.2D2	Degenerative myopia with foveoschisis, left eye
H44.2D3	Degenerative myopia with foveoschisis, bilateral
H44.2E1	Degenerative myopia with other maculopathy, right eye

Miscellaneous ocular condition codes (partial)ICD-10

H44.311	Chalcosis, right eye
H44.312	Chalcosis, left eye
H44.313	Chalcosis, bilateral
H44.321	Siderosis of eye, right eye
H44.322	Siderosis of eye, left eye
H44.323	Siderosis of eye, bilateral
H44.411	Flat anterior chamber hypotony of right eye
H44.412	Flat anterior chamber hypotony of left eye
H44.413	Flat anterior chamber hypotony, bilateral

Globe atrophy/absolute glaucoma/leucocoria codes (partial)ICD-10

H44.511	Absolute glaucoma, right eye
H44.512	Absolute glaucoma, left eye
H44.513	Absolute glaucoma, bilateral
H44.521	Atrophy of globe, right eye
H44.522	Atrophy of globe, left eye
H44.523	Atrophy of globe, bilateral
H44.531	Leucocoria, right eye
H44.532	Leucocoria, left eye
H44.533	Leucocoria, bilateral

Retained intraocular foreign body (magnetic) codes (partial)ICD-10

H44.611	Retained (old) magnetic foreign body in anterior chamber, right eye
H44.612	Retained (old) magnetic foreign body in anterior chamber, left eye
H44.613	Retained (old) magnetic foreign body in anterior chamber, bilateral
H44.621	Retained (old) magnetic foreign body in iris or ciliary body, right eye
H44.622	Retained (old) magnetic foreign body in iris or ciliary body, left eye
H44.623	Retained (old) magnetic foreign body in iris or ciliary body, bilateral
H44.631	Retained (old) magnetic foreign body in lens, right eye
H44.632	Retained (old) magnetic foreign body in lens, left eye
H44.633	Retained (old) magnetic foreign body in lens, bilateral

More retained intraocular foreign body codes (partial)ICD-10

H44.641	Retained (old) magnetic foreign body in posterior wall of globe, right eye
H44.642	Retained (old) magnetic foreign body in posterior wall of globe, left eye
H44.643	Retained (old) magnetic foreign body in posterior wall of globe, bilateral
H44.651	Retained (old) magnetic foreign body in vitreous body, right eye
H44.652	Retained (old) magnetic foreign body in vitreous body, left eye
H44.653	Retained (old) magnetic foreign body in vitreous body, bilateral
H44.691	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, right eye
H44.692	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, left eye
H44.693	Retained (old) intraocular foreign body, magnetic, in other or multiple sites, bilateral

Retained nonmagnetic intraocular foreign body codes (partial)ICD-10

H44.711	Retained (nonmagnetic) (old) foreign body in anterior chamber, right eye
H44.712	Retained (nonmagnetic) (old) foreign body in anterior chamber, left eye
H44.713	Retained (nonmagnetic) (old) foreign body in anterior chamber, bilateral
H44.721	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, right eye
H44.722	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, left eye
H44.723	Retained (nonmagnetic) (old) foreign body in iris or ciliary body, bilateral
H44.731	Retained (nonmagnetic) (old) foreign body in lens, right eye
H44.732	Retained (nonmagnetic) (old) foreign body in lens, left eye
H44.733	Retained (nonmagnetic) (old) foreign body in lens, bilateral

Additional retained foreign body and hemophthalmos codes (partial)ICD-10

H44.741	Retained (nonmagnetic) (old) foreign body in posterior wall of globe, right eye
H44.751	Retained (nonmagnetic) (old) foreign body in vitreous body, right eye
H44.752	Retained (nonmagnetic) (old) foreign body in vitreous body, left eye
H44.753	Retained (nonmagnetic) (old) foreign body in vitreous body, bilateral
H44.791	Retained (old) intraocular foreign body, nonmagnetic, in other or multiple sites, right eye
H44.792	Retained (old) intraocular foreign body, nonmagnetic, in other or multiple sites, left eye
H44.793	Retained (old) intraocular foreign body, nonmagnetic, in other or multiple sites, bilateral
H44.811	Hemophthalmos, right eye
H44.812	Hemophthalmos, left eye
H44.813	Hemophthalmos, bilateral

Optic nerve and globe displacement codes (partial)ICD-10

H44.821	Luxation of globe, right eye
H44.822	Luxation of globe, left eye
H44.823	Luxation of globe, bilateral
H46.01	Optic papillitis, right eye
H46.02	Optic papillitis, left eye
H46.03	Optic papillitis, bilateral
H46.11	Retrobulbar neuritis, right eye
H46.12	Retrobulbar neuritis, left eye
H46.13	Retrobulbar neuritis, bilateral

Optic neuropathy codes (partial)ICD-10

H46.2	Nutritional optic neuropathy
H46.3	Toxic optic neuropathy
H47.011	Ischemic optic neuropathy, right eye
H47.012	Ischemic optic neuropathy, left eye
H47.013	Ischemic optic neuropathy, bilateral

Optic nerve hemorrhage/hypoplasia codes (partial)ICD-10

H47.021	Hemorrhage in optic nerve sheath, right eye
H47.022	Hemorrhage in optic nerve sheath, left eye
H47.023	Hemorrhage in optic nerve sheath, bilateral
H47.031	Optic nerve hypoplasia, right eye
H47.032	Optic nerve hypoplasia, left eye
H47.033	Optic nerve hypoplasia, bilateral

Papilledema/Foster-Kennedy/optic atrophy codes (partial)ICD-10

H47.11	Papilledema associated with increased intracranial pressure
H47.12	Papilledema associated with decreased ocular pressure
H47.13	Papilledema associated with retinal disorder
H47.141	Foster-Kennedy syndrome, right eye
H47.142	Foster-Kennedy syndrome, left eye
H47.143	Foster-Kennedy syndrome, bilateral
H47.211	Primary optic atrophy, right eye
H47.212	Primary optic atrophy, left eye
H47.213	Primary optic atrophy, bilateral

Optic atrophy/coloboma codes (partial)ICD-10

H47.22	Hereditary optic atrophy
H47.231	Glaucomatous optic atrophy, right eye
H47.232	Glaucomatous optic atrophy, left eye
H47.233	Glaucomatous optic atrophy, bilateral
H47.311	Coloboma of optic disc, right eye
H47.312	Coloboma of optic disc, left eye
H47.313	Coloboma of optic disc, bilateral

Drusen/pseudopapilledema codes (partial)ICD-10

H47.321	Coloboma of optic disc, bilateral (formatting duplicated in excerpt)
H47.322	Drusen of optic disc, right eye
H47.323	Drusen of optic disc, left eye
H47.331	Drusen of optic disc, bilateral
H47.332	Pseudopapilledema of optic disc, right eye
H47.333	Pseudopapilledema of optic disc, bilateral

Visual loss codes (partial)ICD-10

H53.121	Transient visual loss, right eye
H53.122	Transient visual loss, left eye
H53.123	Transient visual loss, bilateral
H53.131	Sudden visual loss, right eye
H53.132	Sudden visual loss, left eye
H53.133	Sudden visual loss, bilateral

Post-cataract surgery complication codes (partial)ICD-10

H59.022	Cataract (lens) fragments in eye following cataract surgery, left eye
H59.023	Cataract (lens) fragments in eye following cataract surgery, bilateral
H59.031	Cystoid macular edema following cataract surgery, right eye
H59.032	Cystoid macular edema following cataract surgery, left eye
H59.033	Cystoid macular edema following cataract surgery, bilateral

Neonatal prematurity/low birth weight codes (partial)ICD-10

P07.01	Extremely low birth weight newborn, less than 500 grams
P07.02	Extremely low birth weight newborn, 500-749 grams
P07.03	Extremely low birth weight newborn, 750-999 grams
P07.14	Other low birth weight newborn, 1000-1249 grams
P07.15	Other low birth weight newborn, 1250-1499 grams
P07.16	Other low birth weight newborn, 1500-1749 grams
P07.17	Other low birth weight newborn, 1750-1999 grams
P07.18	Other low birth weight newborn, 2000-2499 grams

Preterm/immaturity codes (partial)ICD-10

P07.21	Extreme immaturity of newborn, gestational age less than 23 completed weeks
P07.22	Extreme immaturity of newborn, gestational age 23 completed weeks
P07.23	Extreme immaturity of newborn, gestational age 24 completed weeks
P07.24	Extreme immaturity of newborn, gestational age 25 completed weeks
P07.25	Extreme immaturity of newborn, gestational age 25-26 completed weeks (formatting inconsistent in excerpt)
P07.26	Extreme immaturity of newborn, gestational age 26 completed weeks

Congenital ocular malformation codes (partial)ICD-10

Q14.0	Congenital malformation of vitreous humor
Q14.1	Congenital malformation of retina
Q14.2	Congenital malformation of optic disc
Q14.3	Congenital malformation of choroid
Q14.8	Other congenital malformations of posterior segment of eye
Q14.9	Congenital malformation of posterior segment of eye, unspecified
Q15.0	Congenital glaucoma

Phakomatoses and related systemic condition codes (partial)ICD-10

Q85.01	Neurofibromatosis, type 1
Q85.02	Neurofibromatosis, type 2
Q85.03	Schwannomatosis
Q85.1	Tuberous sclerosis
Q85.8	Other phakomatoses, not elsewhere classified
Q85.9	Phakomatosis, unspecified
Q87.42	Marfan's syndrome with ocular manifestations (excerpt context)

Traumatic injury ICD-10 codes (partial)ICD-10

S05.11XA	Contusion of eyeball and orbital tissues right eye initial encounter
S05.11XD	Contusion of eyeball and orbital tissues right eye subsequent encounter
S05.11XS	Contusion of eyeball and orbital tissues right eye sequela
S05.12XA	Contusion of eyeball and orbital tissues left eye initial encounter
S05.12XD	Contusion of eyeball and orbital tissues left eye subsequent encounter
S05.12XS	Contusion of eyeball and orbital tissues left eye sequela
S05.21XA	Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter
S05.21XD	Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, subsequent encounter
S05.21XS	Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, sequela

More ocular trauma codes (partial)ICD-10

S05.22XA	Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial encounter
S05.22XD	Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter
S05.22XS	Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela
S05.31XA	Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter
S05.31XD	Ocular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter
S05.31XS	Ocular laceration without prolapse or loss of intraocular tissue, right eye, sequela
S05.32XA	Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter

Penetrating wound codes (partial)ICD-10

S05.32XD	Ocular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter
S05.32XS	Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela
S05.41XA	Penetrating wound of orbit with or without foreign body, right eye, initial encounter
S05.51XA	Penetrating wound with foreign body of right eyeball, initial encounter
S05.51XD	Penetrating wound with foreign body of right eyeball, subsequent encounter
S05.51XS	Penetrating wound with foreign body of right eyeball, sequela
S05.52XA	Penetrating wound with foreign body of left eyeball, initial encounter

Additional penetrating wound encounter codes (partial)ICD-10

S05.52XD	Penetrating wound with foreign body of left eyeball, subsequent encounter
S05.52XS	Penetrating wound with foreign body of left eyeball, sequela
S05.61XA	Penetrating wound without foreign body of right eyeball, initial encounter
S05.61XD	Penetrating wound without foreign body of right eyeball, subsequent encounter
S05.61XS	Penetrating wound without foreign body of right eyeball, sequela
S05.62XA	Penetrating wound without foreign body of left eyeball, initial encounter
S05.62XD	Penetrating wound without foreign body of left eyeball, subsequent encounter
S05.62XS	Penetrating wound without foreign body of left eyeball, sequela

Trauma/complication encounter codes (partial)ICD-10

T74.4XXA	Shaken infant syndrome, initial encounter
T74.4XXD	Shaken infant syndrome, subsequent encounter
T74.4XXS	Shaken infant syndrome, sequela
T85.22XA	Displacement of intraocular lens, initial encounter
T85.22XD	Displacement of intraocular lens, subsequent encounter
T85.22XS	Displacement of intraocular lens, sequela

Listed ICD-10 Codes (part)ICD-10

S05.31XD	Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter
S05.31XS	Ocular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter
S05.32XA	Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela
S05.32XD	Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter
S05.32XS	Ocular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter
S05.41XA	Penetrating wound of orbit with or without foreign body, right eye, initial encounter
S05.42XS	Penetrating wound of orbit with or without foreign body, subsequent encounter (code listed)
S05.51XA	Penetrating wound with foreign body of right eyeball, initial encounter

Listed ICD-10 Codes (continued)ICD-10

S05.51XD	Penetrating wound with foreign body of right eyeball, subsequent encounter
S05.51XS	Penetrating wound with foreign body of right eyeball, sequela
S05.52XA	Penetrating wound with foreign body of left eyeball, initial encounter
S05.52XD	Penetrating wound with foreign body of left eyeball, subsequent encounter
S05.52XS	Penetrating wound with foreign body of left eyeball, sequela
S05.61XA	Penetrating wound without foreign body of right eyeball, initial encounter
S05.61XD	Penetrating wound without foreign body of right eyeball, subsequent encounter
S05.61XS	Penetrating wound without foreign body of right eyeball, sequela
S05.62XA	Penetrating wound without foreign body of left eyeball, initial encounter
S05.62XD	Penetrating wound without foreign body of left eyeball, subsequent encounter

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Provider Actions and Billing Guidance

Billing Rule

Billing: use CPT codes 92201 or 92202

Use CPT 92201 or 92202 when billing for extended ophthalmoscopy; reference current professional coding guidance prior to claim submission. These are the procedure codes the policy references for extended ophthalmoscopy (92201 = extended ophthalmoscopy with retinal drawing and scleral depression; 92202 = extended ophthalmoscopy with drawing of optic nerve or macula) and should be used when documenting and billing the service.

92201 — Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease, with interpretation and report.
92202 — Ophthalmoscopy, extended; with drawing of optic nerve or macula, with interpretation and report.

Documentation Required

Diagnosis coding: use ICD-10 codes listed in policy

Background

Extended ophthalmoscopy is performed after pupil dilation using direct and/or indirect ophthalmoscopy — commonly dilated indirect ophthalmoscopy with scleral depression or contact lens biomicroscopy — to visualize the entire posterior segment including the peripheral retina, optic disc, macula, retinal vessels, choroid and vitreous. The procedure is used when a more detailed examination than routine ophthalmoscopy is required and supports detailed documentation such as a scaled retinal drawing with interpretation and report.

Definitions

inv-65: Extended ophthalmoscopy — definition and brief method description.

DefinitionExtended ophthalmoscopy: a method of examining the posterior portion of the eye when a complete view of the back of the eye is required and documentation exceeds routine ophthalmoscopy.

Typical methodsPerformed after pupil dilation using direct and/or indirect ophthalmoscopy; may use indirect ophthalmoscopy with scleral depression, contact lens biomicroscopy, and detailed retinal drawing with interpretation and report.

Scope of examVisualization of the optic disk, retinal vessels, retina, choroid and vitreous to evaluate posterior segment pathology.

inv-66: Diabetic retinopathy codes (E10–E13 series) — key-value summary referencing ICD-10 group.

Code groupDiabetic retinopathy ICD-10 codes are within the E10–E13 series (type 1, type 2, and other specified diabetes) covering nonproliferative and proliferative retinopathy, with and without macular edema.

Revision History

2023-12updateLatest

Updated medically indicated diagnoses to include new ICD-10 codes.

2023-11review

Updated medically indicated diagnoses to include new ICD-10 codes (documentation entry).

2022-12annual_review

Policy Summary

PayerWellCare

PolicyExtended ophthalmoscopy

Policy CodePolicy CP.VP.26

Change TypeAnnual review (no material changes)

Effective DateN/A

Last ReviewNov 1, 2023

Next Review DateNov 1, 2023

Key ActionWhen billing, use CPT codes 92201 or 92202 and document an anatomically specific retinal drawing with interpretation to support medical necessity.

SourceLink

On This Page

The policy lists numerous ICD-10-CM diagnosis codes that support medical necessity for extended ophthalmoscopy (including diabetes-related retinopathy codes, posterior segment/retinal codes, glaucoma and trauma codes). Verify any plan-level prior authorization requirements separately with the member’s plan before submitting claims.

Examples include E10.*/E11.* diabetic retinopathy codes (see policy listings).
Posterior segment/retinal codes (H30–H33 and many H3x–H4x codes) are provided in the policy.
Glaucoma- and trauma-related ICD-10 codes are also enumerated in the policy.

Prior Authorization

Prior authorization: none specified in excerpt — verify plan-level rules

The provided excerpt does not specify any prior authorization requirement for extended ophthalmoscopy; providers should confirm whether the member’s specific plan or state Medicaid program requires prior authorization before performing or billing the service.

No prior authorization requirements are stated in the policy excerpt.
Check Health Plan- or state Medicaid-level administrative procedures for plan-specific prior auth rules.

Prior Authorization

Prior authorization: no requirements listed in excerpt — check plan procedures

The provided excerpt does not state any plan-level prior authorization conditions in this section; confirm plan administrative rules where the Health Plan may impose additional requirements.

The policy excerpt itself reports no prior authorization rules.
Health Plan-level procedures may still apply and should be checked prior to submission.

Note

Policy applicability: confirm state Medicaid and Medicare NCD/LCD precedence

When applying this clinical policy, ensure consistency with applicable state Medicaid provisions and Medicare NCDs/LCDs; state Medicaid rules take precedence over this clinical policy where they conflict, and applicable Medicare coverage determinations should be reviewed for Medicare members.

State Medicaid coverage provisions take precedence where they conflict with this clinical policy.
Review applicable Medicare NCDs/LCDs and Medicare Coverage Articles prior to applying the criteria for Medicare members.

Note

Provider action: placeholder — follow coding, diagnosis, documentation, and plan rules

(No specific action listed in source excerpt.) Include this placeholder to reflect inventory completeness; providers should follow the coding, diagnosis, documentation, prior authorization, and plan-level guidance contained elsewhere in the policy when submitting claims.

Follow procedure code guidance (CPT 92201/92202), document the supporting ICD-10 diagnosis, and include required extended ophthalmoscopy drawings and interpretation.
Verify plan-level prior authorization and billing rules prior to claim submission.

Note

Provider action: placeholder — ensure documentation & coding accompany claims

(No specific action listed in source excerpt.) This placeholder is included for completeness; rely on the policy’s coding, documentation, and coverage criteria when performing and billing extended ophthalmoscopy.

Ensure documentation (detailed retinal drawing and interpretation) and appropriate ICD-10 diagnosis coding accompany claims.
Use the CPT codes referenced by the policy and confirm plan-level requirements.

Step Therapy

Step therapy: none specified in excerpt

No step therapy requirements for extended ophthalmoscopy are specified in the provided excerpt.

The policy’s step therapy module in the excerpt contains no requirements.
If applicable, check the Health Plan for any administrative step requirements.

Step Therapy

Step therapy: not listed — verify with plan if needed

No step therapy requirements are listed in this excerpt; providers should not assume step therapy applies but must verify plan-level administrative rules.

Policy excerpt does not list step therapy.
Confirm with the member’s plan for any utilization management requirements.

Note

Provider action: placeholder — ensure claims are supported by diagnosis and documentation

(No specific action listed in source excerpt.) Placeholder included for inventory completeness. Providers must ensure claims are supported by the documentation and diagnosis codes listed elsewhere in this policy.

Claims must include an appropriate ICD-10 diagnosis code from the policy and the required extended ophthalmoscopy documentation (detailed retinal drawing with interpretation).

Documentation Required

Documentation required: detailed retinal drawing + interpretation/report

Extended ophthalmoscopy requires a detailed, anatomically specific retinal drawing (disc, macula or periphery) with interpretation and report; the drawing should be clearly labeled and at least 3–4 inches in diameter and include ancillary drawings when defining optic nerve changes.

Drawing must represent normal and abnormal findings (e.g., lattice degeneration, proliferative diabetic retinopathy, detachments, tears, tumors).
Ancillary cup-to-disc drawings (size, depth, rim, vessels, coloration) are required when defining optic nerve changes.

Documentation Required

Medical record: document specific ICD-10 diagnosis to justify service

Medical records must document the specific ICD-10 diagnosis that justifies extended ophthalmoscopy (examples in the policy include diabetic retinopathy codes E10–E13 and posterior segment/retinal codes H30–H33 and related H3x–H4x codes).

Document the precise ICD-10-CM code for the condition being evaluated (e.g., E10.3311, H33.011, etc.).
Ensure the diagnosis on the medical record matches the diagnosis code reported on the claim.

Billing Rule

Diagnosis coding required on claims: use policy-listed ICD-10 codes

The policy provides extensive ICD-10 diagnosis code listings (including H31.x through H40.x ranges and numerous subcodes) corresponding to choroidal, retinal, vitreoretinal, glaucoma, trauma and related conditions; providers should use the applicable code from these lists on claims to support the ophthalmoscopy service.

Use the specific ICD-10-CM code from the policy’s lists that matches the patient’s posterior segment or related ocular condition.
Ensure the claim’s diagnosis code aligns with documentation in the medical record and the policy’s supported codes.

Denial Risk

Claims risk: include an appropriate policy-listed ICD-10 diagnosis on claims

When billing, include an appropriate ICD-10-CM diagnosis code from the policy’s lists on the claim and ensure the medical record contains that same diagnosis and supporting documentation; claims lacking an appropriate policy-listed diagnosis code may be at risk for denial.

Policy lists many ICD-10-CM codes to be used on claims; providers must document the diagnosis in the chart.
Claims not supported by an appropriate ICD-10 diagnosis listed in the policy may be denied.

Note

Documentation & coverage note: policy guides medical necessity but does not guarantee payment

This clinical policy is a guide to medical necessity and does not guarantee payment; coverage decisions are subject to the member’s coverage documents, exclusions, limitations, and applicable law and Health Plan procedures.

Coverage is subject to terms, conditions, exclusions and limitations of the member’s coverage documents.
The clinical policy does not constitute a contract or guarantee of payment.

Denial Risk

Denial risk: routine replacement, duplication, or repeated exams may be denied

Claims for extended ophthalmoscopy may be denied when the service is used routinely to replace standard ophthalmoscopy, when duplicative with other imaging without providing new information, or when repeatedly performed for controlled/stable disease; ensure the clinical record documents why extended ophthalmoscopy provided added clinical value.

Do not use extended ophthalmoscopy as a routine replacement for standard ophthalmoscopy to document healthy retinal anatomy.
Avoid duplicative documentation with fundus photography, fluorescein angiography, etc., unless the extended ophthalmoscopy provides new clinically relevant information.
Repeated exams for controlled/stable disease are designated not medically necessary and may be denied.

Denial Risk

Denial risk: claims not supported by an appropriate ICD-10 diagnosis may be denied

Claims lacking an appropriate ICD-10 diagnosis code from the policy’s listed codes (e.g., the H31–H40 ranges and diabetes-related E10–E13 codes) may be at risk for denial; ensure the claim diagnosis matches the documented clinical indication.

Verify the diagnosis on the claim is one of the ICD-10-CM codes enumerated in the policy that supports medical necessity.
Align claim diagnosis coding with the chart documentation and the policy code lists to reduce denial risk.

Prior Authorization

Authorization/denial: no other explicit triggers in excerpt — focus on documentation and coding

The excerpt does not list additional explicit authorization or denial triggers beyond the coding, documentation, and medical necessity criteria; reviewers focus on whether the indication, diagnosis coding, and required documentation (detailed retinal drawing and interpretation) support medical necessity.

No other authorization/denial triggers are specified in these chunks beyond those related to documentation, duplication, routine replacement, and diagnosis coding.
Ensure required documentation and supported diagnosis codes are present for coverage consideration.

Note

Authorization/denial: not applicable in excerpt

Not applicable in this excerpt — no additional explicit authorization or denial triggers are specified; rely on the policy’s coverage criteria, coding guidance, and documentation requirements.

The excerpt’s denial/authorization content primarily provides ICD-10 listings and documentation requirements rather than additional triggers.
Follow the policy’s stated coverage criteria and documentation rules for adjudication.

Note

Coverage precedence: check state Medicaid and plan-level rules

(Placeholder for completeness.) Providers should follow the policy’s coding, documentation, and coverage guidance and verify any Health Plan-level administrative procedures prior to providing or billing services.

State Medicaid provisions take precedence where they conflict with this clinical policy.
Review plan-level administrative procedures and Medicare NCDs/LCDs where applicable.

Examples (type 1)E10.3291, E10.3311, E10.3391, E10.3411, E10.3511 (variants for right/left/bilateral and severity).

Examples (type 2)E11.3311, E11.3312, E11.3391, E11.3411, E11.3511 (variants for right/left/bilateral and severity).

inv-67: Posterior segment and retinal condition codes (H30–H33 series) — key-value summary referencing ICD-10 group.

Code groupPosterior segment and retinal condition ICD-10 codes are represented in the H30–H33 series covering focal/disseminated chorioretinal inflammation, posterior cyclitis, Harada's disease, macular scars, choroidal detachments, and multiple retinal detachment and tear subtypes.

Representative codesH30.011–H30.023 (focal chorioretinal inflammation), H31.x (choroidal disorders), H33.011–H33.323 (retinal detachment and retinal tears).

Clinical relevanceThese codes support medical necessity for extended ophthalmoscopy when posterior segment disease (e.g., retinal detachment, choroidal detachment, macular pathology) is being evaluated or documented.

inv-68: Extended ophthalmoscopy — note that explicit procedural definition not present in excerpt; diagnosis code relevance noted.

Procedural definition in excerptThe provided excerpt does not include an explicit procedural definition of 'extended ophthalmoscopy' beyond diagnostic code listings and contextual descriptions.

Diagnosis relevancePolicy lists numerous ICD-10 diagnosis codes that indicate clinical situations where extended ophthalmoscopy is applicable (posterior segment, retina, choroid, vitreous, glaucoma, etc.).

Documentation noteMedical records should document the specific ICD-10 diagnosis that justifies extended ophthalmoscopy and include a detailed retinal drawing and interpretation when performed.

inv-69: ICD-10-CM codes — definition of standard diagnosis codes used to describe ocular conditions.

DefinitionICD-10-CM codes: standard diagnosis codes used to describe specific ocular conditions relevant to posterior segment, retinal, choroidal, vitreous, optic nerve, and glaucoma disorders.

UsageProviders must document the applicable ICD-10-CM diagnosis on claims to support medical necessity for extended ophthalmoscopy.

Code ranges citedPolicy cites broad ICD-10 ranges including H30–H40 and E10–E13 series among others to define covered indications.

inv-70: ICD-10-CM code groups — lists related to ocular lacerations, penetrating wounds, displacement codes.

Ocular lacerationsCodes S05.31X–S05.32X cover ocular laceration and rupture with or without prolapse or loss of intraocular tissue (right/left/bilateral, initial/subsequent/sequela).

Penetrating woundsCodes S05.41X–S05.62X cover penetrating wounds of orbit/eyeball with and without foreign body (initial, subsequent, sequela encounters).

Displacement & shaken infantCodes T85.22X (displacement of intraocular lens) and T74.4XX (shaken infant syndrome) are included in the code lists relevant to trauma/complication encounters.

Annual review of policy; administrative updates recorded in review logs.

2022-11annual_review

Annual review of policy (documentation entry).

2021-12annual_review

Annual review and updated medical indications to include iridocyclitis-related diagnoses, premature birth, penetrating orbital wounds, and shaken infant syndrome.

2020-12annual_review

Annual review with updated references.

2020-07template_conversion

Converted policy to new template.

2020-01original_approval

Original policy approval (original approval date: 01/2020).