L28843-LCD

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Local Coverage Determination (LCD) for Fluorescein Angiography (L28843)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28843

LCD Title

Fluorescein Angiography

Contractor's Determination Number A92235

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Fluorescein angiography plays an important role in ophthalmoscopic diagnosis, especially in diagnosing and evaluating many retinal conditions. It has the ability to precisely delineate areas of abnormality, and is an essential guide for planning laser treatment of retinal vascular disease.

Fluorescein angiography is performed by intravascular injection or oral administration of a contrast solution of sodium fluorescein. Ophthalmoscopy performed in conjunction with fluorescein angiography, using a blue filter to excite the fluorescein, is useful in detecting leaking capillaries (subretinal neovascularization). The presence of a permanent record is valuable in the determination of disease progression. Multiple black and white photographs of the ocular fundus at different times following fluorescein injection provide information about vascular obstructions, neovascularization, microaneurysms, abnormal capillary permeability, and defects of the retinal pigment epithelium.

Normal values of a fluorescein angiogram include normal retinal vessels, retina, and choroidal circulation.

Medicare will consider fluorescein angiography medically reasonable and necessary for the following conditions:

-Initial evaluation of a patient with abnormal findings of the fundus/retina on an ophthalmoscopy exam, not limited to the following:

1) Choroidal Neovascular Membranes (CNVM) - these appear as a round-to-oval, greenish-gray lesion(s).

2) Lesions of the Retinal Pigment Epithelium (RPE) - a) serous detachment of the RPE appearing as a round or oval, yellow-orange, sharply demarcated mound; b) tears or rips of the RPE; c) a hemorrhagic detachment appearing as a dark green or red, discretely elevated mound.

3) Fibrovascular disciform scar - lesions varying in color from white to yellow to brown to black, depending upon the degree of retinal pigment epithelial hypertrophy.

4) Vitreous hemorrhage - patient presents with complaints of sudden vision loss.

5) Drusen - appears as pale yellow spots beneath the RPE and represent the earliest clinically detectable feature of age-related macular degeneration.

-Evaluation of a patient presenting with symptoms such as sudden vision loss, especially central vision, blurred vision, distortion, etc., which may suggest that a subretinal neovascularization is present.

-Evaluation of patients with nonproliferative (background) and proliferative diabetic retinopathy, with or without macular edema. Background retinopathy is characterized by intraretinal microaneurysms, hemorrhages, nerve- fiber-layer infarcts, hard exudates and microvascular abnormalities. Proliferative retinopathy is characterized by neovascularization arising either from the disk or from the retinal vessels. Frequency of the fluorescein angiography is dependent on the extent of the disease progression and the treatment performed (e.g., photocoagulation). Fluorescein angiography may be performed on the treated eye only at 6 weeks posttreatment and as often as every 8-12 weeks to assist in management of the retinopathy.

-Evaluation of patients with chorioretinitis, chorioretinal scars of choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment.

-Evaluation of patients with known retinal or macular disorders such as:

1) Age-related macular degeneration (ARMD). ARMD is the leading cause of permanent blindness in the elderly. The disease includes a broad spectrum of clinical and pathologic findings that can be classified into two groups: nonexudative (“dry”) and exudative (“wet”). Although patients with ARMD usually manifest nonexudative changes only, the majority of patients who experience severe vision loss from this disease do so from the development of subretinal neovascularization and related exudative maculopathy.

The management of these two groups differs. Follow-up examination of the treated eye after laser coagulation for exudative macular degeneration is recommended at 1-2 weeks, 1 month, 6 weeks, then every 6-12 months, unless new symptomatology (e.g., sudden central vision loss, distortion) and/or recurrence of subretinal neovascularization (as demonstrated by fluorescein) exists. If recurrent leakage is noted, laser therapy will be repeated, and the fluorescein angiography and fundus photography series will be repeated.

Patients with the nonexudative form of macular degeneration should have regular ophthalmic examinations, including fluorescein angiography performed every 6-12 months, since the exudative stage may develop suddenly at any time, even before patients demonstrate symptomatic visual problems.

2) Macular edema secondary to diabetic retinopathy.

3) Cystoid Macular Edema is caused by fluid accumulating in honeycomb-like spaces of the outer plexiform and inner nuclear layers. On fluorescein angiography, the dye leaks from the perifoveal retinal capillaries and accumulates in a flower-petal pattern about the fovea.

4) Central Retinal Vein Occlusion is a common and easily diagnosed retinal vascular disorder with potentially blinding complications (macular edema and neovascular glaucoma secondary to iris neovascularization). Most eyes will have persistent decreased central vision as a result of chronic macular edema. Fluorescein angiography demonstrates significant retinal capillary nonperfusion in 1/3 of the eyes. Treatment and follow-up are dependent on severity of disease.

5) Branch Retinal Vein Occlusion presents as sudden unilateral vision loss with segmentally distributed intraretinal hemorrhage. Sight-threatening complications of the disease are macular edema, macular ischemia and vitreous hemorrhage from retinal neovascularization. Treatment and follow-up of this disease are dependent on the severity.

Fluorescein angiography and fundus photography are normally performed together. These studies should be performed no greater than 72 hours prior to laser therapy for ARMD because abnormal blood vessels grow at rapid rates, making the studies older than 72 hours inadequate to guide laser treatment.

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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

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.

051X Clinic - General Classification

0920 Other Diagnostic Services - General Classification

CPT/HCPCS Codes

92235 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT

ICD-9 Codes that Support Medical Necessity

115.02 HISTOPLASMA CAPSULATUM RETINITIS

115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED

130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS

135 SARCOIDOSIS

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

224.5 BENIGN NEOPLASM OF RETINA

224.6 BENIGN NEOPLASM OF CHOROID

228.03 HEMANGIOMA OF RETINA

250.50 - 250.53 opens in new window

DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

360.1 PURULENT ENDOPHTHALMITIS UNSPECIFIED

360.2 ACUTE ENDOPHTHALMITIS

360.3 PANOPHTHALMITIS

360.4 CHRONIC ENDOPHTHALMITIS 360.11 - 360.14 opens

in new window SYMPATHETIC UVEITIS - OPHTHALMIA NODOSA

360.20 - 360.24 opens

in new window DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED - OTHER METALLOSIS OF GLOBE

360.55 FOREIGN BODY MAGNETIC IN POSTERIOR WALL

360.65 FOREIGN BODY IN POSTERIOR WALL OF EYE

361.2 SEROUS RETINAL DETACH 362.01 - 362.07* opens

in new window BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA

362.10 - 362.18 opens

in new window BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS

362.21 - 362.29 opens

in new window RETROLENTAL FIBROPLASIA - OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.30 - 362.37 opens

in new window RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA

362.40 - 362.43 opens in new window

362.51 - 362.57 opens in new window

RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

NONEXUDATIVE SENILE MACULAR DEGENERATION OF RETINA - DRUSEN (DEGENERATIVE) OF RETINA

362.65 SECONDARY PIGMENTARY DEGENERATION OF RETINA

362.66 SECONDARY VITREORETINAL DEGENERATIONS

362.70 - 362.77 opens in new window

362.81 - 362.85 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE RETINAL HEMORRHAGE - RETINAL NERVE FIBER BUNDLE DEFECTS

363.00 - 363.08 opens in new window

363.10 - 363.15 opens in new window

363.20 - 363.22 opens

FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY CHORIORETINITIS UNSPECIFIED - HARADA'S DISEASE

363.30 - 363.35 CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA

363.40 - 363.43 opens

in new window CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID

363.50 - 363.57 opens in new window

363.61 - 363.63 opens

HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL

in new window CHOROIDAL HEMORRHAGE UNSPECIFIED - CHOROIDAL RUPTURE

363.70 - 363.72 opens

in new window CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH

364.24 VOGT-KOYANAGI SYNDROME

364.42 RUBEOSIS IRIDIS

368.11 SUDDEN VISUAL LOSS 377.00 - 377.04 opens

in new window PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME

377.16 HEREDITARY OPTIC ATROPHY 377.21 - 377.24 opens

in new window DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA

377.30 - 377.34 opens

in new window OPTIC NEURITIS UNSPECIFIED - TOXIC OPTIC NEUROPATHY

377.41 - 377.49 opens

in new window ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE

379.07 POSTERIOR SCLERITIS

379.22 CRYSTALLINE DEPOSITS IN VITREOUS

794.11 NONSPECIFIC ABNORMAL RETINAL FUNCTION STUDIES

* ICD-9-CM code 362.07 requires a dual diagnosis. When using ICD-9-CM code 362.07 (diabetic macular edema) a code for diabetic retinopathy (362.01-362.06) must also be used.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the fluorescein angiography for each eye. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of study results and interpretation, along with copies of the ordering/referring physician’s order for the study. The physician must state the clinical indication/medical necessity for the study in his order.

Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Bennett, T. The Fundamentals of Fluorescein Angiography. The Ophthalmic Photographers’ Society, Inc. Retrieved from http://www.opsweb.org/Op-Photo/angio/FA/FA1.htm on July 15, 2005.

Medline Plus Medical Encyclopedia. Fluorescein Angiography. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003846.htm on July 27, 2005.

Miller, R. (2005). Miller’s Anesthesia, sixth edition. Pages 2997-2998, Elsevier.

Yanoff, M; Duker, J; Azar, D. et al Eds (2004). Ophthalmology, Second edition. Pages 800-805, Mosby’s.

Advisory Committee Meeting Notes 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 advisory groups, which includes representatives from Florida Society of Ophthalmology.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008

Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28843) replaces LCD L1223 as the policy in notice. This document (L28843) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed

8/1/2010 - The description for Revenue code 0510 was changed 8/1/2010 - The description for Revenue code 0511 was changed 8/1/2010 - The description for Revenue code 0512 was changed 8/1/2010 - The description for Revenue code 0513 was changed 8/1/2010 - The description for Revenue code 0514 was changed 8/1/2010 - The description for Revenue code 0515 was changed 8/1/2010 - The description for Revenue code 0516 was changed 8/1/2010 - The description for Revenue code 0517 was changed 8/1/2010 - The description for Revenue code 0519 was changed 8/1/2010 - The description for Revenue code 0920 was changed

Reason for Change