Ophthalmology and Optometry Coding Alert

Angiography can be performed on one or both eyes. Whether it can be coded bilaterally, however, depends on what the ophthalmologist orders and what the documentation reflects. Even if both eyes are photographed, code for only one unless medical necessity exists for both.
 
Both angiography codes (92235, Fluorescein angiography [includes multiframe imaging] with interpretation and report; and 92240, Indocyanine-green angiography [includes multiframe imaging] with interpretation and report) are unilateral codes. If photos are medically necessary in both eyes, payment increases over performing them in one eye. This article refers mainly to 92235, but bilateral coding rules are usually the same. Indocyanine-green (ICG) is a different kind of dye that may reveal a problem not shown by fluorescein.
  
"In many practices, the technician always takes late photos of the second eye," says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy based in Santa Barbara, Calif. The dye is almost completely through the vessels, with the important pictures of the first eye already taken, when the late photos are done of the second eye. The technician takes late photos to see if something can be detected in that eye even though nothing was seen during the physician's examination.
 
"Because both eyes are photographed, the technician typically charges for both," Duran says. But the procedure should not be billed as bilateral unless medical necessity for both eyes is documented in the chart. "If the notes request FA OU (fluorescein angiography, oculus uterque both eyes), that means do both eyes and bill accordingly. But if the notes request FA OD (oculus dexter right eye), then bill only once." When the notes just say FA and don't indicate whether it is for one or both eyes, final coding rests with the documentation.
 
Medical necessity is usually documented by extended ophthalmoscopy (92225, 92226), which includes a retinal drawing for the chart. Specialized lenses allow the physician to visualize the leakage and then order the photographs to reveal the vascular problem in greater detail.
 
Conditions calling for FA, such as diabetic retinopathy (DR), exist often in both eyes. Certain types of surgery require that both eyes be photographed in advance, e.g., bilateral panretinal laser treatment for proliferative DR. But for bilateral billing the photos must be ordered for both eyes.
 
For example, an ophthalmologist orders FA on a patient with background DR (362.01, Diabetic retinopathy; background diabetic retinopathy) in both eyes but edema (362.83, Other retinal disorders; retinal edema) in only the right eye. There is no medical necessity to perform FAs in both eyes, only in the eye with edema. Bill 92235-RT.
 
In another example, a patient has proliferative DR (362.02) and leaking of fluid in both eyes. There is medical necessity to perform FAs in both eyes. Bill 92235-50 (Bilateral procedure) on one line or, if your carrier prefers, 92235 on one line and 92235-51-50 (Modifier -51, Multiple procedures) on the second line (or 92235-RT [Right side] and 92235-LT [Left side]).

Local Policies

Check local medical review policies (LMRPs) carefully for bilateral billing rules for 92235 and 92240.
 
Consider Nationwide Medicare's recent revision (December 2001) of its LMRP for 92225, 92226, and 92230 (Fluorescein angioscopy with interpretation and report), 92235 and 92240. The carrier, which covers Ohio and West Virginia, requires that two fees be reflected when using modifier -50 with these codes. "CPT codes 92225, 92226, 92230, 92235, and ICG studies are considered unilateral procedures," the LMRP states. "CPT modifier -50 may be used with these codes when appropriate. The quantity billed must reflect 2 when CPT modifier -50 is used with CPT codes 92225, 92226, 92230, 92235, and 92240."
 
Note: The LMRP has a typographical error and refers to 82225 instead of 92225.
 
An LMRP can give insight into a carrier's logic. First Coast, in its LMRP established in 1996, says one rationale for creating the LMRP for 92235 in the first place is that in Florida this procedure was performed over two times more frequently on a bilateral basis when compared to the rest of the country. However, the only way the carrier restricted billing the procedure bilaterally was to issue medical-necessity guidelines, which do not relate to unilateral versus bilateral billing in other words, to try to restrict use of 92235 whether bilateral or not.
 
A highly unusual interpretation comes from Trailblazer, which singles out 92240 for strange treatment. Trailblazer's LMRP says that Medicare will recognize right and left modifiers for only the professional component of 92240: "The technical component may be billed only once, whether one or both eyes are examined." This rule is probably inappropriate, yet it is carrier policy. In another section of the LMRP, Trailblazer notes that if 92235 and 92240 must be done on the same day by the same physician, specific medical necessity is required. For Trailblazer, this means one of the regular covered diagnoses, as well as one of the following:

Evidence of ill-defined subretinal neovascular membrane or suspicious membrane on previous fluorescein angiography; subretinal neovascular membrane not demonstrated by fluorescein angiography in patients with biomicroscopic evidence suggesting a subretinal membrane; subretinal hemorrhage or hemorrhagic retinal pig-ment epithelial detachment; clinical retinal pigment epithelial detachment without evidence of subretinal neovascular membrane on current fluorescein angiogram; or clinical evidence of subretinal membrane with history of allergy to fluorescein.

Testing in Postoperative Period of Laser Treatment

The physician may need photographs in the postoperative period of laser treatment. For example, treatment with 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation) is performed on the left eye, and, a month later, problems start showing up in the right eye. The ophthalmologist orders an FA. The second procedure is billable despite being in the postoperative period because testing services are never included as part of the payment for global services. An office visit is billable as well because the visit is unrelated to the original surgery, which is on a different eye. Bill 92235-LT or 92235-RT, and an E/M (99201-99215) or eye exam code (92002-92014) with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period).