Fluorescein angiography and indocyanine green angiography tests have long been a mainstay of retinal disease management. It’s worth reviewing them and looking at coding changes.

Q. What are fluorescein angiography (FA) and indocyanine green (ICG) angiography?

A. FA is performed by injecting fluorescein into a vein and taking a series of photographs of the retina and choroid as the dye flows through the blood vessels in the eye. ICG is a fluorescent dye that binds to the proteins in plasma, enabling spectral imaging of the optical vascular system. ICG fluoresces in the infrared, which penetrates through the retinal pigment epithelium (RPE), so it allows for an angiogram of the choroidal vasculature.

Q. What are the indications for these tests?

A. FA allows the clinician to evaluate a wide variety of retinal diseases, such as proliferative diabetic retinopathy, macular edema, vascular occlusive disease, age-related macular degeneration, and ocular tumors. Many third-party payers publish policies identifying covered indications for testing.

ICG is performed to assess conditions of the choroid. A few Medicare Administrative Contractors (MACs) have published lists of valid diagnoses. While these lists differ slightly by contractor, the common diagnoses include diseases of the choroid and subretinal anatomy (eg, subretinal neovascular membrane, serous or hemorrhagic detachment of the RPE, and subretinal hemorrhage). Note that covered diagnoses for ICG angiography may overlap with, but are not the same as, those for fluorescein angiography.

Q. What CPT codes describe them?

A. There are 3 codes:

• 92235: fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
• 92240: indocyanine green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
• 92242: fluorescein angiography and ICG angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral

Q. Does Medicare cover FA and ICG?

A. Yes, for covered indications and as part of the overall evaluation and management of disease. For example, FA following treatment of choroidal neovascularization (CNV) is necessary to monitor for recurrence or to detect additional treatable lesions. Medical necessity for testing usually occurs when there is a change in the clinical assessment.

The codes are defined as “unilateral or bilateral,” so they are paid once whether one or both eyes are tested. The 2018 national Medicare Physician Fee Schedule amounts are listed below. These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from Medicare’s.

These codes are subject to Medicare’s Multiple Procedure Payment Reduction (MPPR; http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf ). This reduces the allowable for the technical component of the second and/or lesser-valued test when more than one test is performed on the same day. The MPPR reduction is the same whether the codes are billed as global, or separated into the technical and professional components.

Q. What documentation is required in the medical record to support these claims?

A. A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images or a notation to where they are stored, the medical record should include the following:

• Order for the test with medical rationale,
• Date of the test,
• Reliability of the test (eg, cloudy with cataract),
• Test findings (eg, retinal hemorrhages, neovascularization),
• A diagnosis (if possible),
• The impact on treatment and prognosis, and
• Physician’s signature and date.

Q. Is the physician’s presence required during testing?

A. Yes. Because an intravenous dye is being introduced, direct supervision is indicated. Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the test, but need not be in the room. The supervising physician is shown as the billing physician, even if he or she is not the ordering physician in the group.¹

Q. Are there restrictions on other codes that may be billed the same day?

A. According to CMS’s National Correct Coding Initiative edits, separate reimbursement is allowed for an exam (except 99211) the same day as FA and/or ICG. Most other diagnostic tests are also permitted, although fluorescein angioscopy (92230) is bundled with 92235, and fundus photography (92250) is mutually exclusive with 92240 and 92242.

Q. If coverage is unlikely or uncertain, how should we proceed?

A. Explain why the test is necessary, and that Medicare or other third-party payers will likely deny the claim. Then ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance. An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error. For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms and processes. For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits is an alternative to an ABN. RP

REFERENCE

1. 42 CFR 410.26(b)(5). Billing physician as the supervising physician. https://www.law.cornell.edu/cfr/text/42/410.26 . Accessed May 29, 2018.