Article - Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) (A57069)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations, Chapter 1:80.3 Coverage of photosensitive drugs.Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34175Ophthalmic Angiography (Fluorescein and Indocyanine Green).General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The patient's medical record must contain documentation that fully supports the medical necessity for fluorescein and indocyanine green angiography as it is covered by Medicare. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Copies of fluorescein and indocyanine green angiograms (photographic or digital) must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves.The medical record should include documentation of one of the following when indocyanine green angiography is performed:Evidence of ill-defined subretinal neovascular membrane or suspicious membrane on previous fluorescein angiographyRetinal pigment epithelium (RPE) does not show subretinal neovascular membrane on current fluorescein angiographyPresence of subretinal hemorrhage or hemorrhagic retinal pigment epithelium. A fluorescein angiography need not have been done previously.Evidence of medical necessity must be documented in the medical record for each eye.Documentation, including photos, must be available to Medicare upon request.Fluorescein angiography is considered medically necessary no more than nine (9) times per eye in 365 days. Claims exceeding this frequency will be suspended and reviewed for medical necessity.Indocyanine green angiography is considered medically necessary no more than nine (9) times per eye in 365 days. Claims exceeding this frequency will be suspended and reviewed for medical necessity.Fluorescein angiography performed within 30 days of indocyanine green angiography will be denied as not medically necessary, unless there is documentation in the patient's medical record of co-existing diseases such as age-related macular degeneration or diabetes.For claims submitted to the Part B MAC:CPT code 92235 can be billed in place of service, office (11), ASC, by physician only and not by ASC (24), and independent clinic (49) for the global service or for the technical component (modifier TC). The technical component is also payable in a federally qualified health center (50) and rural health clinic (72.)The professional component, CPT code 92235-26, can be billed in places of service: office (11), inpatient hospital (21), outpatient hospital (22), ASC, by physician only and not by ASC (24), and independent clinic (49).CPT code 92240 can be billed in office (11), ASC, by physician only and not by ASC (24), and independent clinic (49) for the global service or the technical component (modifier TC). The technical component is also payable in a federally qualified health center (50) and rural health clinic (72.)The professional component, CPT code 92240-26, can be billed in office (11), inpatient hospital (21), outpatient hospital (22), ASC, by physician only and not by ASC (24), and independent clinic (49).These procedures are reimbursed on a unilateral basis. Modifier RT or LT must be used if one eye is being tested. If both eyes are being tested, modifier 50 must be reported.CPT codes 92235 and 92240 are all-inclusive. They each include any setup, insertion of intravenous line, injection, cost of dye and the development of the images.An office visit may be reported separately on the same day as fluorescein and ICG services if additional significant and separately identifiable service is rendered.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)