Fluorescein or Indocyanine Green Angiography (L30727)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation
Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402
Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L30727

LCD Title
Fluorescein or Indocyanine Green Angiography

Contractor's Determination Number
OPHTH-016

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Oversight Region
 

Original Determination Effective Date
For services performed on or after 10/16/2010

Original Determination Ending Date


Revision Effective Date
For services performed on or after 02/21/2011

Revision Ending Date


CMS National Coverage Policy
42CFR410.32. Diagnostic tests may only be ordered by treating physicians (or other treating practitioners acting within the scope of their licenses and Medicare requirements) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.
Indications and Limitations of Coverage and/or Medical Necessity
Fluorescein angiography is indicated in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence on leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular disorders and in monitoring the treatment of conditions amenable to laser photocoagulation and anti-VEGF injection therapies.

The dye is injected intravenously and serial photographs are taken through the pupil. While morphological characteristics alone may be pathognomic of certain disease states, the timing of the appearance of the dye in the choroid, in the central retinal artery and in the filling (or otherwise) of the quadrants has diagnostic implications.

Indocyanine Green Angiography is a diagnostic study where indocyanine green dye is injected intravenously. Photographs are taken of the retina at intervals as increasing intensity of retinal and choroidal circulation is displayed.

I. Fluorescein Angiography

Fluorescein angiography is a diagnostic procedure indicated in the evaluation of chorioretinal vascular abnormalities, especially relating to retinal neovascularization, choroidal neovascularization (CNV), non-infective vasculitis, age-related macular degeneration, and diabetic retinopathy. It may also be appropriate in evaluating intraocular tumors, visual loss in systemic disease, and optic disc edema. The medical necessity for such angiography would generally be in the context of a changing clinical picture.

Fluorescein angiography following treatment, for example of CNV or diabetic macular edema, is necessary to monitor for recurrence or to detect additional treatable disease. Usually this is performed on the basis of a change in the clinical picture similar to the way it is employed prior to treatment. However, fluorescein angiography may be performed following treatment without clinical change in order to detect occult lesions. This will occur most often in CNV and very rarely in other diseases such as diabetic macular edema and venous occlusive diagnosis.

II. Indocyanine Green Angiography (ICG)

Indocyanine Green (ICG) Angiography is effective when used in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age-related macular degeneration).

Indocyanine Green Angiography is a valuable diagnostic adjunct to fluorescein angiography in evaluating the following conditions:

- Retinal neovascularization
- Serous detachment of retinal pigment epithelium
- Hemorrhagic detachment of retinal pigment epithelium
- Retinal hemorrhage
- Evidence of ill-defined subretinal neovascular membrane or suspicious membrane on previous fluorescein angiography.
- Retinal Pigment Epithelium (RPE) does not show subretinal neovascular membrane on current fluorescein angiography.
- Presence of subretinal hemorrhage or hemorrhagic retinal pigment epithelium (RPE). A fluorescein angiography need not be previously done.

When medically necessary, in circumstances described above, the fluorescein and the ICG angiography may be performed on the same day. The patients medical record should describe the patient s medical circumstance necessitating the performance of both tests on the same day.

III. Definition of Terms:
Macula: the portion of the retina that sees tiny detail (i.e., read fine print, recognize faces, thread a needle, read time, see street signs, see grains of salt being poured from a shaker). The macula is responsible for sight in the center of the field of vision.

Age-Related Macular Degeneration (AMD): degenerative disease that causes atrophy of the macula. AMD can be described as exudative (wet) and non exudative (dry). The deterioration may be a process of aging, hereditary, or caused by an arteriosclerotic process.

Choroidal Neovascularization (CNV): choroidal capillary proliferation through a break in the outer aspect of Bruch s membrane.

Diabetic Retinopathy: retinal vascular disease causing macular edema and retinal neovascularization which can result in legal or total blindness.


Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
083x Ambulatory Surgery Center
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.


0920 Other Diagnostic Services - General Classification

CPT/HCPCS Codes
92235 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT
92240 INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT

ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.

ICD-9-CM codes for Fluorescein Angiography (92235)
Infectious and Parasitic Diseases

115.02 HISTOPLASMA CAPSULATUM RETINITIS
115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED
130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS
135 SARCOIDOSIS

Neoplasms
190.5 MALIGNANT NEOPLASM OF RETINA
190.6 MALIGNANT NEOPLASM OF CHOROID
198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
224.5 BENIGN NEOPLASM OF RETINA
224.6 BENIGN NEOPLASM OF CHOROID
228.03 HEMANGIOMA OF RETINA
228.09 HEMANGIOMA OF OTHER SITES

Diabetes Mellitus
250.00 - 250.53 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

Other conditions of Brain
348.2 BENIGN INTRACRANIAL HYPERTENSION

Multiple Sclerosis
340 MULTIPLE SCLEROSIS

Disorders of the Globe
360.00 - 360.04 PURULENT ENDOPHTHALMITIS UNSPECIFIED - VITREOUS ABSCESS
360.11 - 360.19 SYMPATHETIC UVEITIS - OTHER ENDOPHTHALMITIS
360.20 - 360.29 DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED - OTHER DEGENERATIVE DISORDERS OF GLOBE
360.30 - 360.33 HYPOTONY OF EYE UNSPECIFIED - HYPOTONY ASSOCIATED WITH OTHER OCULAR DISORDERS

Disorders of Retina
361.10 - 361.14 RETINOSCHISIS UNSPECIFIED - SECONDARY RETINAL CYSTS
361.19 OTHER RETINOSCHISIS AND RETINAL CYSTS
361.2 SEROUS RETINAL DETACH
361.81 TRACTION DETACH OF RETINA
362.01 - 362.07 BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA
362.10 - 362.18 BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS
362.21 RETROLENTAL FIBROPLASIA
362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY
362.30 - 362.37 RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA
362.40 - 362.43 RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM
362.50 - 362.56 MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - MACULAR PUCKERING OF RETINA
362.65 SECONDARY PIGMENTARY DEGENERATION OF RETINA
362.66 SECONDARY VITREORETINAL DEGENERATIONS
362.70 - 362.77 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE
362.81 - 362.85 RETINAL HEMORRHAGE - RETINAL NERVE FIBER BUNDLE DEFECTS
362.9 UNSPECIFIED RETINAL DISORDER

Disorders of Choroid
363.00 FOCAL CHORIORETINITIS UNSPECIFIED
363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY
363.03 - 363.08 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL
363.10 - 363.15 DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY
363.20 - 363.22 CHORIORETINITIS UNSPECIFIED - HARADA'S DISEASE
363.30 - 363.35 CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA
363.40 - 363.43 CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID
363.50 - 363.57 HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL
363.61 - 363.63 CHOROIDAL HEMORRHAGE UNSPECIFIED - CHOROIDAL RUPTURE
363.70 - 363.72 CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH
363.8 OTHER DISORDERS OF CHOROID

Vascular Disorders of Iris
364.42 RUBEOSIS IRIDIS

Visual Disturbances
368.11 SUDDEN VISUAL LOSS
368.14 VISUAL DISTORTIONS OF SHAPE AND SIZE

Disorders of Optic Nerve, Visual Pathway, Sclera and Vitreous Body
377.00 - 377.04 PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME
377.21 DRUSEN OF OPTIC DISC
377.24 PSEUDOPAPILLEDEMA
377.30 - 377.34 OPTIC NEURITIS UNSPECIFIED - TOXIC OPTIC NEUROPATHY
377.41 ISCHEMIC OPTIC NEUROPATHY
377.43 OPTIC NERVE HYPOPLASIA
379.07 POSTERIOR SCLERITIS
379.21 - 379.25 VITREOUS DEGENERATION - VITREOUS MEMBRANES AND STRANDS
379.63 INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 3

Occlusion and Stenosis of Precerebral Arteries
434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION
434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION

Giant Cell Atreritis
446.5 GIANT CELL ARTERITIS

Congenital Anomalies Posterior Segment
743.52 - 743.58 FUNDUS COLOBOMA - VASCULAR ANOMALIES CONGENITAL

Contusion Eyeball
921.3 CONTUSION OF EYEBALL

Follow-up Examinations
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

ICD-9-CM codes for Indocyanine Green Angiography (92240)

Hemangiomas, any site

228.03 HEMANGIOMA OF RETINA

Disorders of Retina
362.16 RETINAL NEOVASCULARIZATION NOS
362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM
362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM
362.52 EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA
362.53 CYSTOID MACULAR DEGENERATION OF RETINA
362.81 - 362.84 RETINAL HEMORRHAGE - RETINAL ISCHEMIA

Disorders of Choroid
363.50 - 363.57 HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL
363.61 CHOROIDAL HEMORRHAGE UNSPECIFIED
363.62 EXPULSIVE CHOROIDAL HEMORRHAGE
363.63 CHOROIDAL RUPTURE
363.72 HEMORRHAGIC CHOROIDAL DETACH
363.8 OTHER DISORDERS OF CHOROID

Disorders of Iris and Ciliary Body
364.00 ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED
364.11 CHRONIC IRIDOCYCLITIS IN DISEASES CLASSIFIED ELSEWHERE

Allergic Reaction to Drug/Biologic Substance
995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE


Diagnoses that Support Medical Necessity
Any listed above
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9-CM codes not listed above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed above

General Information

Documentations Requirements
Physicians services and diagnostic tests must be submitted with an ICD-9 code to support medical necessity and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that most fully explains the narrative description of diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for that diagnosis category. The ICD-9 code based on the results of the test should be reported as the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of sign, symptoms, illness or injury a screening diagnosis should be reported and payment will be denied.

The patient s medical records should be legible, contain the relevant history and physical findings conforming to the criteria stated in the €œIndications and Limitations of Coverage and/or Medical Necessity € section, and must be made available to the Contractor upon request.
Appendices
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Fluorescein Angiography:
1. Melbert, Nancy S., Thomas, Matthew A., et al. 1996. €œSuccessful Feeder Vessel Laser Treatment of Recurrent Neovascularization Following Subfoveal Surgery. € Arch Ophthalmology Volume 144 (February).
2. George, Roger K., et al. 1996. €œPrimary Retinal Vasculitis Systemic Associations and Diagnostic Evaluation. € Ophthalmology Volume 103, Number 3 ( March).
3. Arnold, C., et al. 1996. €œFluoresce in Angiography in Nonischemic Optic Disc Edema €, Arch Ophthalmology Volume 114 (March).
4. Staurenghi, Giovanni, et al. 1996. €œVisualization of Neovascular Membranes with Infrared Light without Dye Injection by Means of a Scanning Laser Ophthalmoscope. € Arch Ophthalmology Volume 114 (March).
5. Macular Photocoagulation Study Group, et al. 1996. €œOccult Choroidal Neovascularization Influence on Visual Outcome in Patients with Age-Related Macular Degeneration. € Arch Ophthalmology Volume 114 (April).
6. Macular Photocoagulation Study Group, et al. 1993. €œLaser Photocoagulation of Subfoveal Neovascular Lesions of Age-Related Macular Degeneration Updated Findings from Two Clinical Trials. € Arch Ophthalmology Volume 111 (September).
7. Jampol, Lee M., M.D. 1991. €œHypertension and Visual Outcome in the Macular Photocoagulation Study. € Arch Ophthalmology Volume 109 (June).
8. The Eye Disease Case-Control Study Group. 1992. €œRisk Factors for Neovascular Age-Related Macular Degeneration. € Arch Ophthalmology Volume 110 (December).
9. National Model Policy

Indocyanine Green Angiography:
1. Archives of Ophthalmology, April 1994, Vol. 112 (4), pp. 465-472.
2. Archives of Ophthalmology, April 1994, Vol. 112 (4), pp. 473-479.
3. Indocyanine green angiography: American Academy of Ophthalmology. Ophthalmology 1998; Aug; 105 (8): 1564-69
4. Ophthalmology, Feb. 1992, Vol. 99 (2), pp.287-291.
5 Retina, 1992, 12 (3), pp. 191-223.
6 Retina, 1993, (3), pp. 266-269.
7. National Model Policy
8. American Academy of Ophthalmology. Ophthalmology 1998; Aug; 105 (8): 1564-69

This policy is an adaptation of a WPS LCD on this topic and other contractor s policies
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 02/12/2010
Illinois 01/13/2010
Michigan 01/27/2010
Minnesota 01/14/2010
Iowa 02/19/2010
Kansas 02/19/2010
Missouri 02/19/2010
Nebraska 02/19/2010
Open Meeting: 01/06/2010

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from Ophthalmology.

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier and fiscal intermediary predecessors of Wisconsin Physicians Service.
This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated Wisconsin Physician Services (formerly Mutual of Omaha) to process their claims
Start Date of Comment Period
02/19/2010
End Date of Comment Period
04/05/2010
Start Date of Notice Period
09/01/2010
Revision History Number
1
Revision History Explanation
09/01/2010: removed frequency from Utilization Section (one).

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).

02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
Reason for Change
Last Reviewed On Date
08/01/2010
Related Documents
This LCD has no Related Documents.

LCD Attachments

NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now.

Page Last Updated: Wednesday, 05-Oct-2011 11:23:47 CDT