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Extended ophthalmoscopy is a specialized diagnostic procedure that involves a comprehensive examination of the internal structures of the eye, particularly the back of the eye, known as the fundus. This examination is more detailed than a standard intermediate or comprehensive ophthalmological exam and is specifically designed to assess severe posterior segment pathologies. During the procedure, the physician administers eyedrops to dilate the pupil and anesthetize the surface of the eye, facilitating a clearer view of the internal structures. An ophthalmoscope, which resembles a flashlight, is utilized to project a beam of light through the dilated pupil, allowing the physician to examine the retina, optic disc, choroid, and blood vessels through various tiny lenses. Additionally, a slit lamp microscope may be employed to enhance the examination. The physician meticulously examines the back of the eye and creates a detailed drawing of the optic nerve or macula, which is essential for documenting the extent of any retinal detachment, the location of holes or tears, areas of traction, vitreous opacities, hemorrhaging, lesions, or tumors. This documentation is crucial for specific conditions such as glaucoma, where the physician must identify various characteristics of the optic nerve, including cupping, disc rim, pallor, slope, and any surrounding pathology. The procedure culminates in the generation of an interpretation report that summarizes the findings, conclusions, and impressions derived from the examination, ensuring that all relevant details are captured for further evaluation and management.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of extended ophthalmoscopy is indicated for a variety of conditions that necessitate a thorough examination of the posterior segment of the eye. The following are the explicitly provided indications for performing this procedure:
The procedure of extended ophthalmoscopy involves several key steps that ensure a comprehensive evaluation of the eye's internal structures. The following procedural steps are outlined:
Following the extended ophthalmoscopy procedure, patients may experience temporary effects from the dilating eyedrops, such as blurred vision and light sensitivity. It is recommended that patients arrange for transportation home, as their ability to drive may be impaired. The physician will provide instructions regarding any follow-up appointments or additional tests that may be necessary based on the findings of the examination. Patients should also be advised to monitor for any unusual symptoms, such as sudden vision changes, and to report these to their healthcare provider promptly.
| Short Descr | OPSCPY EXTND ON/MAC DRAW | Medium Descr | OPSCPY EXTND OPTIC NRV/MACULA DRAWING I&R UNI/BI | Long Descr | Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 2 - 150% payment adjustment does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | STV-Packaged Codes | Type of Service (TOS) | Q - Vision Items or Services | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | LT | Left side (used to identify procedures performed on the left side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | RT | Right side (used to identify procedures performed on the right side of the body) | GW | Service not related to the hospice patient's terminal condition | GC | This service has been performed in part by a resident under the direction of a teaching physician | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | GA | Waiver of liability statement issued as required by payer policy, individual case | 24 | Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service. | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 57 | Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | E4 | Lower right, eyelid | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | JZ | Zero drug amount discarded/not administered to any patient | P2 | A patient with mild systemic disease | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | QW | Clia waived test | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner |
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| 2020-01-01 | Added | Code added. |
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