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
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 |
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
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 |
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 |
| 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
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 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed above
General Information
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.
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
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
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).
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
