As a medical coding company providing ophthalmology medical coding services, we are well aware that one of the most significant changes in 2017 was the introduction of CPT code 92242.
92242 Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral.
Fluorescein and indocyanine green angiography are considered valuable diagnostic tools in patients with diabetic retinopathy, retinal and macular disorders, and certain ocular tumors and optic disc diseases. In both procedures, which mainly differ in terms of the type of dye used, the dye is injected into the patient’s vein. When the dye reaches the retina and is exposed to a specific light wavelength, the areas it enters become visible. Photographs taken of the blood vessels in the fundus allow the physician to inspect the structure and identify leaks.
The reason why code 92242 was introduced is the high volume of Medicare claims involving same-day use of codes 92235 Fluorescein angiography and 92240 ICG performance. Here, it is important to note that payment for CPT codes 92235 and 92240 changed significantly effective Jan. 1, 2017. The changes reflecting relative value units (RUVs) recommended by the American Medical Association’s Relative Value-Scale Update Committee (“RUC”) are as follows:
- Work RVUs are based on physician time and intensity – Fluorescein angiography: 17 minutes; Indocyanine-green angiography: 22 minutes, and FA/ICG: 22 minutes.
- Practice expense RVUs are based on tech time and supplies.
- Equipment cost constitutes a minor role.
Moreover, CMS recognized that bilateral testing does not involve double the work, for e.g., the patient is taken to a testing room and positioned only once. Therefore, the CPT description now includes unilateral or bilateral for these ophthalmology codes, and CMS pays the same whether one or both eyes are tested.
Submitting 92235 and 92240 for the same session is considered unbundling, and is not appropriate. Instead, 92242 should be used to report fluorescein and indocyanine green angiography performed at the same encounter. According to a report published by the American Academy of Ophthalmology (AAO), a typical scenario in which the service represented by code 92242 would be provided is that of a 77-year-old patient with a history of dry age-related macular degeneration who presents with subretinal blood and fluid. Other guidelines from the AAO on the use of 92242:
- Bill once per encounter – 92242 is payable once whether one or both eyes are tested. When only one eye is tested, the unique eye modifier–52, which represents a reduced service, should not be appended.
- Direct supervision – The test should be performed under direct supervision of a physician, that is, the physician must be onsite when it is performed. This physician does not have to be the physician who ordered the test.
- Correct Coding Initiative (CCI) edits that can be unbundled – CPT code 92242 is not typically payable the same day together with the following CPT codes: 36000, 36200, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248, 36410, 76000, 76001, 77001, 77002, 92230, 92250, 93000, 93005, 93010, 93040, 93041, 93042, 96360, 96365, 96372, 96374, 96375, 96376, 96377, 99211, and 99446. However, under certain circumstances, 92242 can be billed with one of these codes, even if the services are performed by the same provider for the same patient on the same day. These circumstances should be indicated by unbundling, which refers to the process of appending a modifier to one of the codes.
- CCI edits that cannot be unbundled – Most important, 92242 has mutually exclusive edits with CPT codes 36591, 36592, 92235 FA, 92240 ICG, 96523, 99446, 99447, 99448, and 99449. Under no circumstances can you bill for 92242 and any of those 9 codes on the same day for the same patient. If you do, you will only be paid for 1 code-probably the least remunerative
- No Local Coverage Determinations (LCDs) or Frequency Edits – The AAO points out that no LCDs or frequency edits have been published for combined FA and ICG indicating how often 92242 can be performed annually. However, the frequency edit may be embedded in the payer system.
- Medicare coverage – Medicare’s payment for 92242 is approximately $232, though this varies based on geographic region. As the test is covered by Medicare Part B, it must also be covered by Medicare Advantage plans.
- Billing commercial payers – Many commercial plans do not recognize the new code 92242 for combined FA and ICG. In this situation, the AAO recommends that physicians participating with the plan go by the directions in the remittance advice or appeal using data from the equipment company. Providers can check with the private payer as whether it is covered/payable before performing the test.
Some providers do not own the new equipment that performs both FA and ICG, but still perform both tests on the same patient on the same day. To their question as to whether they should bill both 92235 and 92240, or only 92242, the AAO advises they should continue to submit 92235 and 92240. However, in this case, payers may ask why 92242 was not submitted and request records to verify accuracy of the claim.
Reliable medical billing and coding companies keep track of changes in CPT and ICD-10 codes as well as industry regulations and payer specifics. Billing for any specialty is much easier with such expert support.
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