CODING Q&A

Threading the Coding Needle for ICG Angiography

BY SUZANNE CORCORAN, COE

Here we address how to successfully obtain reimbursement for ICG angiography.

Q. DOES MEDICARE COVER ICG ANGIOGRAPHY?

A. Yes, when medically necessary. Ophthalmologists perform ICG angiography to assess conditions of the choroid. Most Medicare Administrative Contractors (MACs) have published lists of valid diagnoses. While these lists differ slightly from contractor to contractor, the common diagnoses include diseases of the choroid and subretinal anatomy (eg, SRNVM, serous or hemorrhagic RPE detachment, and subretinal hemorrhage. Check your local Medicare coverage policy for a detailed list.

Q. HOW SHOULD WE DOCUMENT ICG ANGIOGRAPHY IN THE MEDICAL RECORD?

A. Besides the digital images, the medical record should contain:

• an order for the test,

• with medical rationale;

• date of test;

• patient consent for the test;

• reliability of the test (eg, cloudy due to cataract);

• test findings (eg, hemorrhage), including comparison with previous tests if applicable;

• diagnosis (if possible);

• impact on treatment and prognosis; and

• physician’s signature.

Q. IS THE PHYSICIAN’S PRESENCE REQUIRED WHILE THE ICG IS PERFORMED?

A. Yes. Under Medicare standards, this test requires direct supervision. This means the physician must be available in the office to assist if needed. The physician’s presence in the exam room throughout the test is not required.

Q. HOW MUCH DOES MEDICARE ALLOW?

A. Use CPT code 92240 to describe ICG on claims for reimbursement. This is a “unilateral” service, so each eye is reimbursed separately. The 2014 national Medicare Physician Fee Schedule allowable is $255.77. Of this amount, $190.22 is assigned to the technical component and $65.56 to the value of the professional component (ie, interpretation). These amounts are adjusted in each area based on local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

92240 is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the second and/or lesser-valued test when the physician performs more than one test on the same day.

Q. HOW WILL MY PAYMENT DIFFER IF THIS TEST OCCURS IN A HOSPITAL SETTING?

A. The ophthalmologist bills only for the interpretation of the test (ie, professional component) as 92240-26. The hospital outpatient department bills for taking the photographs.

Q. ARE OTHER TESTS OR SERVICES BUNDLED WITH 92240?

A. According to Medicare’s National Correct Coding Initiative (NCCI) edits, fundus photography (92250) and fluorescein angioscopy (92230) are bundled with ICG. When the practice performs these tests on the same day, Medicare will reimburse the ICG, but not the other tests. The E/M service 99211 is also bundled with this test. OCT (92133, 92134) is not bundled under the NCCI edits, but some MACs do; check your local policies.

Q. HOW DOES MEDICARE TREAT ICG WHEN PERFORMED WITH FLUORESCEIN ANGIOGRAPHY (92235)?

A. Both ICG angiography and fluorescein angiography are reimbursed, as long as medical necessity exists for both. Because the NCCI does not offer an edit or a bundle of these services, separate payment is allowed for each test. Note that each test requires its own order, images, and interpretation.

Q. MAY I EVER BILL THE MEDICARE BENEFICIARY DIRECTLY FOR THIS SERVICE?

A. Yes. Sometimes an ophthalmologist may feel that these tests are merited, although the indications do not match Medicare’s coverage list. In such situations, in which Medicare may challenge the medical necessity of the service, the practice should have the patient sign an Advance Beneficiary Notice of Noncoverage before testing. With this signed form on file, the physician may then collect from the patient for the service.

Q. HOW FREQUENTLY IS THIS TEST PERFORMED?

A. Medicare utilization rates for claims paid in 2012 showed that ICG angiography was performed at 0.5% of all office visits by ophthalmologists. Note that this service is billed per eye, and the 0.5% represents tests rather than patients. Note also that the data included ophthalmologists of all subspecialties; retina specialists will probably have higher utilization.

Q. HOW OFTEN MAY WE REPEAT ICG ANGIOGRAPHY ON A PATIENT?

A. No published limitations exist for repeated ICG angiography. In general, this and all diagnostic tests are reimbursed when they are medically indicated. Medicare always requires clear documentation of the reason for testing. RP