Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 1 of 12 Extended OphthalmoscopyPOLICY HISTORY Last Review: 10/26/2021 Effective: 08/14/2009 Next Review: 08/25/2022 Review History Definitions Additional Information Clinical Policy Bulletin Notes Number: 0767 POLICY *Please see amendment for Pennsylvania Medicaid at the end of this CPB. Aetna considers extended ophthalmoscopy with a detailed retinal drawing for evaluation of the posterior portion of the eye following routine ophthalmoscopy medically necessary for any of the following indications: Blunt injury to the eye or periorbital structures; or Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment; or Choroidal nevus being evaluated for malignant transformation; or Degenerative disorders of the globe; or Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy retinal vascular occlusion, or separation of the retinal layers); or Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment); or High axial length myopia (-6.00 Diopters or less [toward -10.00 D]); or High-risk medication for retinopathy or optic neuropathy; or HIV retinopathy; or Macular degeneration; or Malignant neoplasm of the retina or choroid; or Metamorphopsia; or
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0767 Extended Ophthalmoscopy Medical Clinical Policy Bulletins
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Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 1 of 12
Extended Ophthalmoscopy
POLICY HISTORY
Last Review: 10/26/2021
Effective: 08/14/2009
Next Review: 08/25/2022
Review History
Definitions
Additional Information Clinical Policy Bulletin
Notes
Number: 0767
POLICY *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Aetna considers extended ophthalmoscopy with a detailed retinal drawing
for evaluation of the posterior portion of the eye following routine
ophthalmoscopy medically necessary for any of the following indications:
Blunt injury to the eye or periorbital structures; or
Chorioretinitis, chorioretinal scars or choroidal degeneration,
dystrophies, hemorrhage and r upture, or detachment; or
Choroidal nevus being evaluated for malignant transformation; or
Degenerative disorders of the globe; or
Diabetic retinopathy (i.e., background retinopathy or proliferative
retinopathy retinal vascular occlusion, or separation of the retinal
layers); or
Disorders of the vitreous body (i.e., vitreous hemorrhage or
posterior vitreous detachment); or
High axial length myopia (-6.00 Diopters or less [toward -10.00 D]);
or
High-risk medication for retinopathy or optic neuropathy; or
HIV retinopathy; or
Macular degeneration; or
Malignant neoplasm of the retina or choroid; or
Metamorphopsia; or
Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 2 of 12
Optic atrophy associated with a progressive and potentially
reversible cause (e.g., glaucoma); or
Penetrating wound to the orbit resulting in the retention of a
foreign body in the eye; or
Posterior scleritis; or
Retained (old) intra-ocular foreign body, either magnetic or non-
magnetic; or
Retinal defects without retinal detachment; or
Retinal detachment, with or without retinal defect; or
Retinal edema; or
Retinal hemorrhage, ischemia, exudates and deposits, hereditary
retinal dystrophies or peripheral retinal degeneration; or
Retinopathy of prematurity; or
Retinoschisis and retinal cysts; or
Sudden visual loss or transient visual loss; or
Suspected endophthalmitis as evidenced by severe pain, redness,
photophobia, and profound loss of vision; or
Symptoms suggestive of retinal defect; or
Systemic disorders associated with retinal pathology; or
Uncontrolled glaucoma or glaucoma suspect; or
Vogt-Koyanagi syndrome characterized by bilateral uveitis,
dysacousia, meningeal irritation, whitening of patches of hair
(poliosis), vitiligo, and retinal detachment.
Note: Extended ophthalmoscopy with a detailed retinal drawing for
evaluation of the posterior portion of the eye is considered not medically
necessary when initial routine ophthalmoscopy showed normal clinical
tears, or tumors. Where extended ophthalmoscopy is used in defining
optic nerve changes, ancillary drawings of cup to disc data elements
(size, depth, rim, vessels, coloration) are required to fulfill obligations for
documentation.
Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 5 of 12
A standard approach to documenting retinal disease is to use a color-
coded scheme; however, such color coding is not a requirement. Where
color coding is not used, a description of the anatomy and pathology of
the fundus and periphery is required. There is more than one
professionally accepted color scheme. An example of one such color
scheme includes the color red for hemorrhage, flat retina and retinal hole;
blue for detached retina, retinal veins and outline of retinal tear; green for
vitreous pathology; brown for choroidal findings; black for changes to the
retinal pigment epithelium and blood vessels; yellow for retinal exudates;
and black outline filled with black lattice pattern for lattice degeneration of
attached retina.
CPT Codes/ HCPCS Codes/ICD-10 CodesInformation in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by “+”
Code Code Description
CPT codes covered if selection criteria are met:
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 with drawing of optic nerve or macula (e.g., for glaucoma,
macular pathology, tumor) with interpretation and report,
unilateral or bilateral
ICD-10 codes covered if selection criteria are met:
Code Code Description
C69.20 -
C69.32
Malignant neoplasm of retina or choroid
D31.30 -
D31.32
Benign neoplasm of choroid [evaluation of choroidal nevus for malignant transformation]
E08.311,
E08.3211 -
E08.3219,
E08.3311 -
E08.3319,
E08.3411 -
E08.3419,
E08.3511 -
Diabetes mellitus due to underlying condition with ophthalmic
complications
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E08.3559,
E09.311,
E09.3211 -
E09.3219,
E09.3311 -
E09.3319,
E09.3411 -
E09.3419,
E09.3511 -
E09.3559,
E10.311,
E10.3211 -
E10.3219,
E10.3311 -
E10.3319,
E10.3411 -
E10.3419,
E10.3511 -
E10.3559,
E11.311,
E11.3211 -
E11.3219,
E11.3311 -
E11.3319,
E11.3411 -
Code Code Description
E11.3419,
E11.3511 -
E11.3559,
E13.311,
E13.3211 -
E13.3219,
E13.3311 -
E13.3319,
E13.3411 -
E13.3419,
E13.3511 -
E13.3559
Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 7 of 12
Code Code Description
E09.311 -
E09.39
Drug or chemical induced diabetes mellitus
E10.311 -
E10.39
E11.311 -
E11.39
E13.311 -
E13.39
Diabetes with ophthalmic complications, type I, type II or
unspecified type
G45.3 Amaurosis fugax
H05.50 -
H05.53
Retained (old) foreign body following penetrating w ound of orbit
H15.031 -
H15.039
Posterior scleritis
H16.241 -
H16.249
H21.331 -
H21.339
H33.121 -
H33.129
H44.001 -
H44.539
H44.811 -
H44.819
Disorders of the globe
Code Code Description
H20.821 -
H20.829
Vogt-Koyanagi syndrome
H30.001 - H32
H35.33
Disorders of choroid and retina
H31.101 -
H31.129
H34.00 -
H35.3293
H35.341 - H36
Other retinal disorders
Extended Ophthalmoscopy - Medical Clinical Policy Bulletins | Aetna Page 8 of 12