LCD/NCD Portal

L29197

 

INDOCYANINE-GREEN ANGIOGRAPHY

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

• Medicare will consider indocyanine - green (ICG) angiography to be medically necessary as an adjunct to fluorescein angiography (FA) in the evaluation of the following conditions:

o Serous detachment of retinal pigment epithelium

o Hemorrhagic detachment of retinal pigment epithelium

o Retinal hemorrhage

o Presence of subretinal hemorrhage or hemorrhagic retinal pigment epithelium (RPE). A fluorescein angiography need not be previously done if patient is allergic to fluorescein

o Central serous retinopathy

o Focal and disseminated choroiditis

• In the absence of pre-existing chronic disease, clinical signs or symptoms of disease, an ICG angiography is considered screening and is not a benefit of the Medicare program.

• Also, a bilateral study is not automatically appropriate, or covered, in every case.

• Therefore, evidence of medical necessity must be documented in the medical record for each eye.

• Contraindications to ICG angiography include

o prior ananaphylactic reaction to ICG dye or contrast agents that contain iodide,

o liver disease,

o Uremia.

o Pregnancy.

 

CPT/HCPCS Codes

 

 

92240 INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT

 

 

ICD-9 Codes that Support Medical Necessity

 

362.41 CENTRAL SEROUS RETINOPATHY

362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM

362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.81 RETINAL HEMORRHAGE

363.00 FOCAL CHORIORETINITIS UNSPECIFIED

363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY

363.03 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE

363.04 FOCAL CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.05 FOCAL RETINITIS AND RETINOCHOROIDITIS JUXTAPAPILLARY

363.06 FOCAL RETINITIS AND RETINOCHOROIDITIS MACULAR OR PARAMACULAR

363.07 FOCAL RETINITIS AND RETINOCHOROIDITIS OF OTHER POSTERIOR POLE

363.08 FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

363.10 DISSEMINATED CHORIORETINITIS UNSPECIFIED

363.11 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS POSTERIOR POLE

363.12 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.13 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS GENERALIZED

363.14 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS METASTATIC

363.15 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 CHORIORETINITIS UNSPECIFIED

 

 

Documentation Requirements

• Medical record documentation maintained by the performing physician must indicate the medical necessity of the indocyanine - green angiography.

• Office records/progress notes must document

o the complaint,

o symptomatology, or

o reason necessitating the test and

o Must include the examination results/findings.

Utilization Guidelines

• Following the performance of indocyanine - green angiography, fluorescein angiography can be considered medically necessary and reimbursable when performed on the same eye, within a one month timeframe of the ICG.

o Both procedures (i.e., ICG, FA) may be allowed on the same day when additional diagnostic information is medically necessary.

• Generally, only one ICG is medically necessary prior to and following a course of treatment.

o Services in excess of this standard of care must be reflected in the patients’ medical records to support the medical necessity of more frequent testing.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Treatment Logic

• Indocyanine – green (ICG) angiography is an infrared-based, dye imaging technique that is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age - related macular degeneration).

• Indocyanine - green dye is injected intravenously into the patient to highlight the vessels in the retina and those of a deeper tissue layer called the choroid.

• The green dye fluoresces with invisible infrared light and requires a special camera sensitive to these light rays.

• Photographs are then taken of the retina at intervals as increasing intensity of retinal and choroidal circulation is displayed.

 

Sources of Information and Basis for Decision

 

Charters, L. (2001). New diagnostic tools can help to identify CSC disorder. Ophthalmology Times, 26(6), 58-60. Retrieved August 18, 2004, from Proquest.umi.com database (70064123).

 

Chopdar, A., Chakravarthy, U., Verma, D. (2003). Age related macular degeneration. British Medical Journal, 326(7387), 485-489. Retrieved August 18, 2004, Proquest.umi.com database (320589311).

 

Ciardella, A., Borodoker, N., Costa, D., Huang, S., Cunningham, E., & Slakter, J. (2002). Imaging the posterior segment in uveitis. Ophthalmology Clinics of North America, 15(3). Retrieved July 20, 2004, from mdconsult.com database (39229780).

 

Glenn, C. (2001). Revisiting feeder vessel treatment. Review of Ophthamology, 8(8), 41-45.

 

Nissen, D. (Ed.). (2004). Mosby’s Drug Consult. St. Louis, MO: Mosby.

 

Yanoff. (2004). Ophthalmology (2nd ed.). St. Louis, MO: Mosby.

 

Zarfati, D., Harris, A., Garzozi, H., Zacish, M., Kagemann, L., Jonescu-Cuypers, C., Martin, B. (2000). A review of ocular blood flow measurement techniques. Neuro-Ophthalmology, 24(3), 401-410.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 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.

 

CMS LCD L29197 Indocyanine-Green Angiography