Medicare Reimbursement for Fluorescein and ICG Angiography (Heidelberg)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR FLUORESCEIN AND ICG ANGIOGRAPHY

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Q What are fluorescein and indocyanine-green angiography (FA and ICG) performed with the SPECTRALIS^®?

A FA is a test that allows imaging of the vascular system in the retina and choroid. It 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 degenera-tion, and ocular tumors, as well as other retinal pathology. 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 from contractor to contractor, the common diagnoses include diseases of the choroid and subretinal anatomy (e.g., SRNVM, serous or hemorrhagic detachment of the RPE, and subretinal hemorrhage). Note that covered diagnoses for ICG angiography may over-lap with, but are not the same as, those for fluores-cein angiography. Check your local Medicare coverage policy for a detailed list.

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 in the presence of a change in the clinical assessment. Check your local coverage determination (LCD) policy for guidance.

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

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

order for the test with medical rationale
date of the test
reliability of the test (e.g., cloudy due to cataract)
test findings (e.g., retinal hemorrhages, neovascularization)
comparison with prior tests (if applicable)
a diagnosis, (if possible)
the impact on treatment and prognosis
physician’s signature

Q Is the physician’s presence required during testing?

A Yes. Because an intravenous dye is being introduced, direct supervision is indicated. Direct supervision in the office setting 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 not be in the room. The claim must identify the supervising physician as the billing physician.^1.,2.

Q What CPT codes should we use to describe these tests?

A There are 3 codes:

Q What does Medicare allow for these tests?

A The 2018 national Medicare Physician Fee Schedule amounts are as follows. These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from Medicare’s.

Since 2017, the codes are defined as “unilateral or bilateral” so are paid once whether one or both eyes are tested.
These codes are subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the second or lesser-valued test when more than one test is performed on the same day.

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

A According to Medicare’s National Correct Coding Initiative (NCCI) edits, separate reimbursement is allowed for FA and/or ICG when performed in conjunction with an exam (except 99211). 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 payer will likely deny the claim. 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.
For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

1. 42 CFR 410.26(b)(5). Billing physician as the supervising physician. Accessed 01/05/18.

2. 80 FR 70885 CMS-1631-FC. 2016 Medicare Program; revisions to payment policies under the physician fee schedule. Published Nov 16, 2015. Accessed 01/05/18.

Provided Courtesy of Heidelberg Engineering (800) 931-2230

Last updated March 25, 2018

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

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