Download Local Coverage Determination for Ophthalmic Angiography

Local Coverage Determination (LCD):
Ophthalmic Angiography (Fluorescein and Indocyanine Green)
(L34175)
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Contractor Information
Contractor Name
CGS Administrators,
CGS Administrators,
CGS Administrators,
CGS Administrators,
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LLC
LLC
LLC
LLC
Contract Type Contract Number Jurisdiction State(s)
MAC - Part A
15101 - MAC A
N/A
Kentucky
MAC - Part B
15102 - MAC B
N/A
Kentucky
MAC - Part A
15201 - MAC A
N/A
Ohio
MAC - Part B
15202 - MAC B
N/A
Ohio
LCD Information
Document Information
LCD ID
L34175
Original Effective Date
For services performed on or after 10/01/2015
Original ICD-9 LCD ID
L31882
Revision Effective Date
For services performed on or after 10/01/2015
LCD Title
Ophthalmic Angiography (Fluorescein and Indocyanine
Green)
Revision Ending Date
N/A
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Printed on 4/27/2016. Page 1 of 17
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N/A
Notice Period Start Date
N/A
Notice Period End Date
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UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS
MANUAL, 2014, is copyrighted by American Hospital
Association (“AHA”), Chicago, Illinois. No portion of
OFFICIAL UB-04 MANUAL may be reproduced, sorted in
a retrieval system, or transmitted, in any form or by
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written notice to Company.
CMS National Coverage Policy Language 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, italicized text 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.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Abstract:
Fluorescein
Fluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible
fluorescence on leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular
disorders and monitoring treatment of conditions amenable to laser photocoagulation.
The dye is injected intravenously and serial photographs are taken through the pupil. While morphological
characteristics alone may be pathognomonic of certain disease states, the timing of appearance of the dye in the
choroid, in the central retinal artery and in the filling (or otherwise) of the quadrants have diagnostic implications.
Indocyanine Green
Indocyanine green dye is injected intravenously into the patient to highlight the vessels in the retina and the
deeper tissue layer of the choroid. Under infrared light, Indocyanine Green fluoresces allowing the choroidal
vessels to be visualized through the retinal pigment epithelium or in the presence of retinal or vitreous
hemorrhage that would otherwise obscure visualization. Indocyanine green angiography (ICG) is effective in the
diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular
degeneration). It is also useful in the evalution of feeder vessels, choroidal leakages in the late phase, and
Printed on 4/27/2016. Page 2 of 17
ruptures of the pigment epithelium.
Indications:
Fluorescein
Fluorescein angiography with interpretation is medically necessary as an adjunct to the diagnosis of chorioretinal
vascular abnormalities especially relating to choroid neovascularization, noninfective vasculitis, and age related
macular degeneration. It may also be appropriate in evaluating intraocular tumors, visual loss in systemic
disease, acute exudative inflammations such as toxoplasmosis and optic disc edema. Medical necessity for such
angiography would generally be in the context of a changing clinical picture. Fluorescein angiography may be
useful in diabetic retinopathy in identifying ischemia and neovascularization, locating microaneurysms, and
defining macular edema.
Fluorescein angiography following treatment, for example, of choroidal neovascularization (CNV) is necessary to
monitor for recurrence or to detect additional treatable disease. Usually this is performed on the basis of a
change in the clinical picture similar to the way it is employed prior to treatment. However, fluorescein
angiography may be performed following treatment without clinical change in order to detect occult lesions. This
will occur most often in CNV and very rarely in other diseases.
Indocyanine Green
Indocyanine green angiography (ICG) may be a valuable diagnostic adjunct to fluorescein angiography in the
evaluation of the following conditions:
•
•
•
•
•
Retinal neovascularization
Choroid neovascularization
Serous detachment of retinal pigment epithelium
Hemorrhagic detachment of retinal pigment epithelium
Retinal hemorrhage
Limitations:
Fluorescein
Studies performed for screening will be denied by Medicare as not medically necessary.
Fluorescein angiography must be performed under the direct supervision (physician present in the office and
immediately available) of a physician when done by a non-physician practitioner.
If excluded by State law, optometrists may not be reimbursed for fluorescein angiography.
Fluorescein angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic
exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of
medical necessity must be documented in the medical record for each eye.
Indocyanine Green
Indocyanine green angiography must be performed under the direct supervision (physician present in the office
and immediately available) of a physician when done by a non-physician practitioner.
If excluded by State law, optometrists may not be reimbursed for ICG angiography.
Indocyanine green is formulated with iodine and should not be used on patients who are allergic to iodine.
ICG for the evaluation of patients with background diabetic retinopathy is not considered to be a medically
necessary service.
ICG angiography of an asymptomatic contralateral eye without new abnormalities on ophthalmoscopic exam, in
patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical
necessity must be documented in the medical record for each eye.
Studies performed for screening will be denied by Medicare as not medically necessary.
Other Comments:
Printed on 4/27/2016. Page 3 of 17
For claims submitted to the Part A MAC: This coverage determination also applies within states outside the
primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their
claims.
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.
Limitation of liability and refund requirements apply when denials are based on medical necessity. The
provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is
aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of
liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no
Medicare benefit category or is rendered for screening purposes.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include nonphysicians, 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.)
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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.
N/A
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.
Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to
physicians, other professional and suppliers who bill these services to the carrier or Part B MAC.
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the
FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code.
Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
032X
040X
052X
092X
096X
Radiology - Diagnostic - General Classification
Other Imaging Services - General Classification
Freestanding Clinic - General Classification
Other Diagnostic Services - General Classification
Professional Fees - General Classification
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
92235 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT
INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND
92240
REPORT
Printed on 4/27/2016. Page 4 of 17
ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: It is the responsibility of the provider to code to the highest level specified in the ICD-10CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must
be reasonable and necessary in the specific case and must meet the criteria specified in this determination.
ICD-10-CM Codes for Fluorescein Angiography (92235)
Group 1 Codes:
ICD-10 Codes
Description
A18.53
Tuberculous chorioretinitis
B20
Human immunodeficiency virus [HIV] disease
B58.01
Toxoplasma chorioretinitis
C69.21
Malignant neoplasm of right retina
C69.22
Malignant neoplasm of left retina
C69.31
Malignant neoplasm of right choroid
C69.32
Malignant neoplasm of left choroid
D18.09
Hemangioma of other sites
D31.21
Benign neoplasm of right retina
D31.22
Benign neoplasm of left retina
D31.31
Benign neoplasm of right choroid
D31.32
Benign neoplasm of left choroid
D57.01
Hb-SS disease with acute chest syndrome
D57.02
Hb-SS disease with splenic sequestration
D57.1
Sickle-cell disease without crisis
D57.20
Sickle-cell/Hb-C disease without crisis
D57.211
Sickle-cell/Hb-C disease with acute chest syndrome
D57.212
Sickle-cell/Hb-C disease with splenic sequestration
D57.80
Other sickle-cell disorders without crisis
D57.811
Other sickle-cell disorders with acute chest syndrome
D57.812
Other sickle-cell disorders with splenic sequestration
D86.0 - D86.3 Sarcoidosis of lung - Sarcoidosis of skin
D86.81 Sarcoid meningitis - Sarcoidosis of other sites
D86.89
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with
E08.321
macular edema
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy
E08.329
without macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy
E08.331
with macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy
E08.339
without macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy
E08.341
with macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy
E08.349
without macular edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular
E08.351
edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without
E08.359
macular edema
E08.36
Diabetes mellitus due to underlying condition with diabetic cataract
E08.39
Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with
E09.321
macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy
E09.329
without macular edema
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy
E09.331
with macular edema
E09.339
Printed on 4/27/2016. Page 5 of 17
ICD-10 Codes
Description
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy
without macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with
E09.341
macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy
E09.349
without macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular
E09.351
edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without
E09.359
macular edema
E09.36
Drug or chemical induced diabetes mellitus with diabetic cataract
E09.39
Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication
E10.321
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.329
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular
E10.331
edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular
E10.339
edema
E10.341
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular
E10.349
edema
E10.351
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.359
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.36
Type 1 diabetes mellitus with diabetic cataract
E10.39
Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.65
Type 1 diabetes mellitus with hyperglycemia
E11.321
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.329
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular
E11.331
edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular
E11.339
edema
E11.341
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular
E11.349
edema
E11.351
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.359
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E11.36
Type 2 diabetes mellitus with diabetic cataract
E11.39
Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.65
Type 2 diabetes mellitus with hyperglycemia
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular
E13.321
edema
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular
E13.329
edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with
E13.331
macular edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without
E13.339
macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular
E13.341
edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without
E13.349
macular edema
E13.351
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.359
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema
E13.36
Other specified diabetes mellitus with diabetic cataract
E13.39
Other specified diabetes mellitus with other diabetic ophthalmic complication
G35
Multiple sclerosis
G45.3
Amaurosis fugax
G93.2
Benign intracranial hypertension
H30.001 Unspecified focal chorioretinal inflammation, right eye - Unspecified focal chorioretinal
H30.003
inflammation, bilateral
Printed on 4/27/2016. Page 6 of 17
ICD-10 Codes
H30.011 H30.013
H30.021 H30.023
H30.031 H30.033
H30.041 H30.043
H30.101 H30.103
H30.111 H30.113
H30.121 H30.123
H30.131 H30.133
H30.141 H30.143
H30.21 H30.23
H30.811 H30.813
H30.891 H30.893
H31.021 H31.023
H31.101 H31.103
H31.111 H31.113
H31.121 H31.123
H31.21
H31.29
H31.321 H31.323
H31.411 H31.413
H31.421 H31.423
H33.101 H33.103
H33.111 H33.113
H33.191 H33.193
H33.21 H33.23
H34.01 H34.03
H34.11 H34.13
H34.231 H34.233
H34.811 H34.813
H34.821 H34.823
H34.831 H34.833
H34.9
H35.00
Description
Focal chorioretinal inflammation, juxtapapillary, right eye - Focal chorioretinal inflammation,
juxtapapillary, bilateral
Focal chorioretinal inflammation of posterior pole, right eye - Focal chorioretinal inflammation of
posterior pole, bilateral
Focal chorioretinal inflammation, peripheral, right eye - Focal chorioretinal inflammation,
peripheral, bilateral
Focal chorioretinal inflammation, macular or paramacular, right eye - Focal chorioretinal
inflammation, macular or paramacular, bilateral
Unspecified disseminated chorioretinal inflammation, right eye - Unspecified disseminated
chorioretinal inflammation, bilateral
Disseminated chorioretinal inflammation of posterior pole, right eye - Disseminated chorioretinal
inflammation of posterior pole, bilateral
Disseminated chorioretinal inflammation, peripheral right eye - Disseminated chorioretinal
inflammation, peripheral, bilateral
Disseminated chorioretinal inflammation, generalized, right eye - Disseminated chorioretinal
inflammation, generalized, bilateral
Acute posterior multifocal placoid pigment epitheliopathy, right eye - Acute posterior multifocal
placoid pigment epitheliopathy, bilateral
Posterior cyclitis, right eye - Posterior cyclitis, bilateral
Harada's disease, right eye - Harada's disease, bilateral
Other chorioretinal inflammations, right eye - Other chorioretinal inflammations, bilateral
Solar retinopathy, right eye - Solar retinopathy, bilateral
Choroidal degeneration, unspecified, right eye - Choroidal degeneration, unspecified, bilateral
Age-related choroidal atrophy, right eye - Age-related choroidal atrophy, bilateral
Diffuse secondary atrophy of choroid, right eye - Diffuse secondary atrophy of choroid, bilateral
Choroideremia
Other hereditary choroidal dystrophy
Choroidal rupture, right eye - Choroidal rupture, bilateral
Hemorrhagic choroidal detachment, right eye - Hemorrhagic choroidal detachment, bilateral
Serous choroidal detachment, right eye - Serous choroidal detachment, bilateral
Unspecified retinoschisis, right eye - Unspecified retinoschisis, bilateral
Cyst of ora serrata, right eye - Cyst of ora serrata, bilateral
Other retinoschisis and retinal cysts, right eye - Other retinoschisis and retinal cysts, bilateral
Serous retinal detachment, right eye - Serous retinal detachment, bilateral
Transient retinal artery occlusion, right eye - Transient retinal artery occlusion, bilateral
Central retinal artery occlusion, right eye - Central retinal artery occlusion, bilateral
Retinal artery branch occlusion, right eye - Retinal artery branch occlusion, bilateral
Central retinal vein occlusion, right eye - Central retinal vein occlusion, bilateral
Venous engorgement, right eye - Venous engorgement, bilateral
Tributary (branch) retinal vein occlusion, right eye - Tributary (branch) retinal vein occlusion,
bilateral
Unspecified retinal vascular occlusion
Unspecified background retinopathy
Printed on 4/27/2016. Page 7 of 17
ICD-10 Codes
H35.021 H35.023
H35.031 H35.033
H35.041 H35.043
H35.051 H35.053
H35.061 H35.063
H35.071 H35.073
H35.09
H35.21 H35.23
H35.30 H35.33
H35.341 H35.343
H35.351 H35.353
H35.371 H35.373
H35.381 H35.383
H35.52 H35.54
H35.61 H35.63
H35.711 H35.713
H35.721 H35.723
H35.731 H35.733
H35.81
H35.82
H44.21 H44.23
H46.01 H46.03
H47.011 H47.013
H47.10
H47.11 H47.13
H47.141 H47.143
H47.321 H47.323
H47.331 H47.333
H47.391 H47.393
H59.031 H59.033
M05.411
M05.412
M05.421
M05.422
M05.431
Description
Exudative retinopathy, right eye - Exudative retinopathy, bilateral
Hypertensive retinopathy, right eye - Hypertensive retinopathy, bilateral
Retinal micro-aneurysms, unspecified, right eye - Retinal micro-aneurysms, unspecified, bilateral
Retinal neovascularization, unspecified, right eye - Retinal neovascularization, unspecified,
bilateral
Retinal vasculitis, right eye - Retinal vasculitis, bilateral
Retinal telangiectasis, right eye - Retinal telangiectasis, bilateral
Other intraretinal microvascular abnormalities
Other non-diabetic proliferative retinopathy, right eye - Other non-diabetic proliferative
retinopathy, bilateral
Unspecified macular degeneration - Angioid streaks of macula
Macular cyst, hole, or pseudohole, right eye - Macular cyst, hole, or pseudohole, bilateral
Cystoid macular degeneration, right eye - Cystoid macular degeneration, bilateral
Puckering of macula, right eye - Puckering of macula, bilateral
Toxic maculopathy, right eye - Toxic maculopathy, bilateral
Pigmentary retinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium
Retinal hemorrhage, right eye - Retinal hemorrhage, bilateral
Central serous chorioretinopathy, right eye - Central serous chorioretinopathy, bilateral
Serous detachment of retinal pigment epithelium, right eye - Serous detachment of retinal
pigment epithelium, bilateral
Hemorrhagic detachment of retinal pigment epithelium, right eye - Hemorrhagic detachment of
retinal pigment epithelium, bilateral
Retinal edema
Retinal ischemia
Degenerative myopia, right eye - Degenerative myopia, bilateral
Optic papillitis, right eye - Optic papillitis, bilateral
Ischemic optic neuropathy, right eye - Ischemic optic neuropathy, bilateral
Unspecified papilledema
Papilledema associated with increased intracranial pressure - Papilledema associated with retinal
disorder
Foster-Kennedy syndrome, right eye - Foster-Kennedy syndrome, bilateral
Drusen of optic disc, right eye - Drusen of optic disc, bilateral
Pseudopapilledema of optic disc, right eye - Pseudopapilledema of optic disc, bilateral
Other disorders of optic disc, right eye - Other disorders of optic disc, bilateral
Cystoid macular edema following cataract surgery,
cataract surgery, bilateral
Rheumatoid myopathy with rheumatoid arthritis of
Rheumatoid myopathy with rheumatoid arthritis of
Rheumatoid myopathy with rheumatoid arthritis of
Rheumatoid myopathy with rheumatoid arthritis of
Rheumatoid myopathy with rheumatoid arthritis of
Printed on 4/27/2016. Page 8 of 17
right eye - Cystoid macular edema following
right shoulder
left shoulder
right elbow
left elbow
right wrist
ICD-10 Codes
M05.432
M05.441
M05.442
M05.451
M05.452
M05.461
M05.462
M05.471
M05.472
M05.49
M05.511
M05.512
M05.521
M05.522
M05.531
M05.532
M05.541
M05.542
M05.551
M05.552
M05.561
M05.562
M05.571
M05.572
M05.59
M05.711
M05.712
M05.721
M05.722
M05.731
M05.732
M05.741
M05.742
M05.751
M05.752
M05.761
M05.762
M05.771
M05.772
M05.79
M05.811
M05.812
M05.821
M05.822
M05.831
M05.832
M05.841
M05.842
M05.851
M05.852
M05.861
M05.862
M05.871
Description
Rheumatoid myopathy with rheumatoid arthritis of left wrist
Rheumatoid myopathy with rheumatoid arthritis of right hand
Rheumatoid myopathy with rheumatoid arthritis of left hand
Rheumatoid myopathy with rheumatoid arthritis of right hip
Rheumatoid myopathy with rheumatoid arthritis of left hip
Rheumatoid myopathy with rheumatoid arthritis of right knee
Rheumatoid myopathy with rheumatoid arthritis of left knee
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of multiple sites
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems
involvement
Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems
involvement
Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems
involvement
Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems
involvement
Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems
involvement
Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems
involvement
Other rheumatoid arthritis with rheumatoid factor of right shoulder
Other rheumatoid arthritis with rheumatoid factor of left shoulder
Other rheumatoid arthritis with rheumatoid factor of right elbow
Other rheumatoid arthritis with rheumatoid factor of left elbow
Other rheumatoid arthritis with rheumatoid factor of right wrist
Other rheumatoid arthritis with rheumatoid factor of left wrist
Other rheumatoid arthritis with rheumatoid factor of right hand
Other rheumatoid arthritis with rheumatoid factor of left hand
Other rheumatoid arthritis with rheumatoid factor of right hip
Other rheumatoid arthritis with rheumatoid factor of left hip
Other rheumatoid arthritis with rheumatoid factor of right knee
Other rheumatoid arthritis with rheumatoid factor of left knee
Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
Printed on 4/27/2016. Page 9 of 17
ICD-10 Codes
M05.872
M05.89
M06.011
M06.012
M06.021
M06.022
M06.031
M06.032
M06.041
M06.042
M06.051
M06.052
M06.061
M06.062
M06.071
M06.072
M06.08
M06.09
M06.211
M06.212
M06.221
M06.222
M06.231
M06.232
M06.241
M06.242
M06.251
M06.252
M06.261
M06.262
M06.271
M06.272
M06.28
M06.29
M06.311
M06.312
M06.321
M06.322
M06.331
M06.332
M06.341
M06.342
M06.351
M06.352
M06.361
M06.362
M06.371
M06.372
M06.38
M06.39
M06.811
M06.812
M06.821
M06.822
M06.831
M06.832
M06.841
M06.842
Description
Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
Other rheumatoid arthritis with rheumatoid factor of multiple sites
Rheumatoid arthritis without rheumatoid factor, right shoulder
Rheumatoid arthritis without rheumatoid factor, left shoulder
Rheumatoid arthritis without rheumatoid factor, right elbow
Rheumatoid arthritis without rheumatoid factor, left elbow
Rheumatoid arthritis without rheumatoid factor, right wrist
Rheumatoid arthritis without rheumatoid factor, left wrist
Rheumatoid arthritis without rheumatoid factor, right hand
Rheumatoid arthritis without rheumatoid factor, left hand
Rheumatoid arthritis without rheumatoid factor, right hip
Rheumatoid arthritis without rheumatoid factor, left hip
Rheumatoid arthritis without rheumatoid factor, right knee
Rheumatoid arthritis without rheumatoid factor, left knee
Rheumatoid arthritis without rheumatoid factor, right ankle and foot
Rheumatoid arthritis without rheumatoid factor, left ankle and foot
Rheumatoid arthritis without rheumatoid factor, vertebrae
Rheumatoid arthritis without rheumatoid factor, multiple sites
Rheumatoid bursitis, right shoulder
Rheumatoid bursitis, left shoulder
Rheumatoid bursitis, right elbow
Rheumatoid bursitis, left elbow
Rheumatoid bursitis, right wrist
Rheumatoid bursitis, left wrist
Rheumatoid bursitis, right hand
Rheumatoid bursitis, left hand
Rheumatoid bursitis, right hip
Rheumatoid bursitis, left hip
Rheumatoid bursitis, right knee
Rheumatoid bursitis, left knee
Rheumatoid bursitis, right ankle and foot
Rheumatoid bursitis, left ankle and foot
Rheumatoid bursitis, vertebrae
Rheumatoid bursitis, multiple sites
Rheumatoid nodule, right shoulder
Rheumatoid nodule, left shoulder
Rheumatoid nodule, right elbow
Rheumatoid nodule, left elbow
Rheumatoid nodule, right wrist
Rheumatoid nodule, left wrist
Rheumatoid nodule, right hand
Rheumatoid nodule, left hand
Rheumatoid nodule, right hip
Rheumatoid nodule, left hip
Rheumatoid nodule, right knee
Rheumatoid nodule, left knee
Rheumatoid nodule, right ankle and foot
Rheumatoid nodule, left ankle and foot
Rheumatoid nodule, vertebrae
Rheumatoid nodule, multiple sites
Other specified rheumatoid arthritis, right shoulder
Other specified rheumatoid arthritis, left shoulder
Other specified rheumatoid arthritis, right elbow
Other specified rheumatoid arthritis, left elbow
Other specified rheumatoid arthritis, right wrist
Other specified rheumatoid arthritis, left wrist
Other specified rheumatoid arthritis, right hand
Other specified rheumatoid arthritis, left hand
Printed on 4/27/2016. Page 10 of 17
ICD-10 Codes
M06.851
M06.852
M06.861
M06.862
M06.871
M06.872
M06.88
M06.89
Q14.8
Z09
Z79.3
Z79.891
Z79.899
Description
Other specified rheumatoid arthritis, right hip
Other specified rheumatoid arthritis, left hip
Other specified rheumatoid arthritis, right knee
Other specified rheumatoid arthritis, left knee
Other specified rheumatoid arthritis, right ankle and foot
Other specified rheumatoid arthritis, left ankle and foot
Other specified rheumatoid arthritis, vertebrae
Other specified rheumatoid arthritis, multiple sites
Other congenital malformations of posterior segment of eye
Encounter for follow-up examination after completed treatment for conditions other than
malignant neoplasm
Long term (current) use of hormonal contraceptives
Long term (current) use of opiate analgesic
Other long term (current) drug therapy
Group 2 Paragraph: 92235
Use ICD-10-CM B39.9 with the following
Group 2 Codes:
ICD-10 Codes
Description
H32
Chorioretinal disorders in diseases classified elsewhere
Group 3 Paragraph: ICD-10-CM Codes For Indocyanine Green Angiography (92240)
Group 3 Codes:
ICD-10 Codes
Description
A18.53
Tuberculous chorioretinitis
H30.101 Unspecified disseminated chorioretinal inflammation, right eye - Unspecified disseminated
H30.103
chorioretinal inflammation, bilateral
H30.111 Disseminated chorioretinal inflammation of posterior pole, right eye - Disseminated chorioretinal
H30.113
inflammation of posterior pole, bilateral
H30.121 Disseminated chorioretinal inflammation, peripheral right eye - Disseminated chorioretinal
H30.123
inflammation, peripheral, bilateral
H30.131 Disseminated chorioretinal inflammation, generalized, right eye - Disseminated chorioretinal
H30.133
inflammation, generalized, bilateral
H31.8
Other specified disorders of choroid
H32
Chorioretinal disorders in diseases classified elsewhere
H35.051 Retinal neovascularization, unspecified, right eye - Retinal neovascularization, unspecified,
H35.053
bilateral
H35.09
Other intraretinal microvascular abnormalities
H35.32
Exudative age-related macular degeneration
H35.61 Retinal hemorrhage, right eye - Retinal hemorrhage, bilateral
H35.63
H35.711 Central serous chorioretinopathy, right eye - Central serous chorioretinopathy, bilateral
H35.713
H35.721 Serous detachment of retinal pigment epithelium, right eye - Serous detachment of retinal
H35.723
pigment epithelium, bilateral
H35.731 Hemorrhagic detachment of retinal pigment epithelium, right eye - Hemorrhagic detachment of
H35.733
retinal pigment epithelium, bilateral
ICD-10 Codes that DO NOT Support Medical Necessity
Group 1 Paragraph: Use of any ICD-10-CM code not listed in the "ICD-10-CM Codes that Support
Medical Necessity" section of this LCD will be denied. In addition, the following ICD-10-CM codes are
specifically listed as not supporting medical necessity for emphasis for indocyanine green
angiography, and to avoid any provider errors.
Printed on 4/27/2016. Page 11 of 17
Group 1 Codes:
ICD-10
Description
Codes
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular
E08.311
edema
Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular
E08.319
edema
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with
E08.321
macular edema
Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy
E08.329
without macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy
E08.331
with macular edema
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy
E08.339
without macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with
E08.341
macular edema
Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy
E08.349
without macular edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular
E08.351
edema
Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without
E08.359
macular edema
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular
E09.311
edema
Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular
E09.319
edema
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with
E09.321
macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without
E09.329
macular edema
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy
E09.331
with macular edema
Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy
E09.339
without macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with
E09.341
macular edema
Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy
E09.349
without macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular
E09.351
edema
Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular
E09.359
edema
E10.311
Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319
Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.321
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.329
Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E10.331
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular
E10.339
edema
E10.341
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.349
Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E10.351
Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.359
Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E11.311
Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319
Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.321
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.329
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E11.331
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular
E11.339
edema
E11.341
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
Printed on 4/27/2016. Page 12 of 17
ICD-10
Codes
E11.349
E11.351
E11.359
E13.311
E13.319
E13.321
E13.329
E13.331
E13.339
E13.341
E13.349
E13.351
E13.359
H35.00
Description
Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular
edema
Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular
edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular
edema
Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without
macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular
edema
Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular
edema
Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema
Unspecified background retinopathy
ICD-10 Additional Information
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General Information
Associated Information
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
angiography
Retinal pigment epithelium (RPE) does not show subretinal neovascular membrane on current fluorescein
angiography
Presence 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.
Not applicable
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.
Printed on 4/27/2016. Page 13 of 17
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.
Sources of Information and Basis for Decision
This bibliography presents those sources that were obtained during the development of this policy. CGS
Administrators, LLC. is not responsible for the continuing viability of Web site addresses listed below.
Arevalo JF, Fuenmayor-Rivera D, Giral AE, Murcia E. Inflammation of the posterior uvea: findings on fundus
fluorescein and indocyanine green angiography. Ocul Immunol Inflamm. 2006;14(3):171-9.
Bakri SJ, Sculley LA, Sing AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13.
Available from:
http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.
Battaglia PM, Da Pozzo S, Ravalico G. Angiographic pattern of recurrent choroidal neovascularization in agerelated macular degeneration. Eye. 2004;18(7):685-90.
Bennett T. Fundamentals of fluorescein angiography indications and uses Ophthalmic Photographers Society.
Available from: http://www.opsweb.org/OpPhoto/Angio/FA/FA3.html Accessed on 4/6/2007.
Bischoff P, Helbig H, Niederberger H, Torok B. Simultaneous ICG- and fluorescein-angiography for fundus
examination. Klin Monatsbl Augenheilkd. 2000;216(2):120-5. German.
Bischoff PM, Niederberger HJ, Torok B, Speiser P. Simultaneous indocyanine green and fluorescein angiography.
Retina. 1995;15(2):91-9.
Bottoini FG, Aandekerk AL, Deutman AF. Clinical application of digital indocyanine green videoangiography in
senile macular degeneration. Graefes Arch Clin Exp Ophthalmol. 1994;232(8):458-68.
Bouchenaki N, Cimino L, Auer C, Tao Tran V, Herbort CP. Assessment and classification of choroidal vasculitis in
posterior uveitis using indocyanine green angiography. Klin Monatsbl Augenheilkd. 2002;219(4):243-9.
Carrier Medical Director Ophthalmology Clinical Workgroup.
Cimino L, Auer C, Herbort CP. Indocyanine green videoangiography of multifocal Cryptococcus neoformans
choroiditis in a patient with acquired immunodeficiency syndrome. Retina. 2001;21(5):537-41.
Coscas G, Coscas F, Soubrane G. Monitoring the patient after treatment: angiographic aspects of recurrence and
indications for retreatment. J Fr Ophtalmol. 2004;27(1):81-92. French.
Dyer DS, Brant AM, Schachat AP, Bressler SB, Bressler NM. Angiographic features and outcome of questionable
recurrent choroidal neovascularization. Am J Ophthalmol. 1995;120(4):497-505.
Guyer D. Principles of Indocyanine-Green Angiography, Retina Vitreous-Macula. W.B.Saunders. 1999;chapter
3:39-46.
Helbig H, Niederberger H, Valmaggia C, Bischoff P. Simultaneous fluorescein and indocyanine green angiography
for exudative macular degeneration. Klin Monatsbl Augenheilkd. 2005;222(3):202-5.
Jampol, Lee M. Hypertension and Visual Outcome in the Macular Photocoagulation Study. Arch Ophthalmol.
1991;109(6):789-790.
Khairallah M, Ben Yahiak S, Attia S, et al. Indocyanine green angiographic features in multifocal chorioretinitis
associated with West Nile virus infection. Retina. 2006;26(3):358-9.
Kramer M, Mimouni K, Priel E, Yassur Y, Weinberger D. Comparison of fluorescein angiography and indocyanine
green angiography for imaging of choroidal neovascularization in hemorrhagic age-related macular degeneration.
Am J Ophthalmol. 2000;129(4):495-500.
Mandava N. Principles of Fluorescein Angiography, Retina Vitreous-Macula. W.B.Saunders. 1999;chapter 4:29-38.
Mayfeild J. Who cares about the quality of diabetes care? Almost everyone! Clin Diabetes 1998;16(4).Available
at: http://journal.diabetes.org/clinicaldiabetes/v16n41998/Mayfield.htm. Accessed July 21, 2006.
Printed on 4/27/2016. Page 14 of 17
National Guideline Clearinghouse. Age-related macular degeneration. Limited revision. www.guideline.gov.
Accessed July 21, 2006.
National Guideline Clearinghouse. Care of the patient with retinal detachment and related peripheral vitreoretinal
disease. Available at: www.guideline.gov. Accessed July 21, 2006.
No authors listed. Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration.
Updated findings from two clinical trials. Macular Photocoagulation Study Group. Arch Ophthalmol.
1993;111(9):1200-9.
No authors listed. Persistent and recurrent neovascularization after krypton laser photocoagulation for
neovascular lesions of age-related macular degeneration. Macular Photocoagulation Study Group. Arch
Ophthalmol. 1990;108(6):825-31.
No authors listed. Persistent and recurrent neovascularization after krypton laser photocoagulation for
neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group. Arch Ophthalmol.
1989;107(3):344-52.
No authors listed, Recurrent choroidal neovascularization after argon laser photocoagulation for neovascular
maculopathy. Macular Photocoagulation Study Group. Arch Ophthalmol. 1986;104(4):503-12.
Obana A, Gohto Y, Matsumoto M, Miki T, Nishiguti K. Indocyanine green angiographic features prognostic of
visual outcome in the natural course of patients with age related macular degeneration. British Journal of
Ophthalmology. 1999;83:429-437.
Other carrier policy (Empire Medical Services [effective 01/01/2006] L2170 R1). Available at:
http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed December 7, 2006.
Other carrier policy (First Coast Service Options [effective 10/01/2005] L1223 R3). Available at:
http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed July 21, 2006.
Other carrier policy (WPS [effective 10/01/2006] L17998 R9). Available at:
http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed December 7, 2006.
Other carrier policy (WPS [effective 10/01/2006] L17997 R6). Available at:
http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649. Accessed July 21, 2006.
Other carrier policy: Riverbend Government Benefits Administrator Local Coverage Determination Indocyanine
Green Angiography (#L1244). Accessed July 21, 2006.
Other carrier policy: Wheatlands Administrative Services Local Coverage Determination Indocyanine Green
Angiography and Angioscopy (#L22232). Accessed July 21, 2006.
Pece A, Sannace C, Menchini U, et al. Fluorescein angiography and indocyanine green angiography for identifying
occult choroidal neovascularization in age-related macular degeneration. Eur J Ophthalmol. 2005;15(6):759-63.
Regillo CD, Blade KA, Custis PH, O'Connell SR. Evaluating persistent and recurrent choroidal neovascularization:
The role of indocyanine green angiography. Ophthalmology 1998;105:1821-1826.
Regillo CD, Benson WE, Maguire JI, Annesley WH Jr. Indocyanine green angiography and occult choroidal
neovascularization. Ophthalmology. 1994;101(2):280-8.
Reichel E, Duker JS, Puliafito CA. Indocyanine green angiography and choroidal neovascularization obscured by
hemorrhage. Ophthalmology. 1995;102:1871-1876.
Risk Factors for Neovascular Age-Related Macular Degeneration. The Eye Disease Case-Control Study Group,
1992. Arch Ophthalmology. 1992;110.
Sing RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195208. Available at http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15,
2006.
Slakter JS, Giovannini A, Yannuzzi LA, et al. Indocyanine green angiography of multifocal choroiditis.
Ophthalmology. 1997;104(11):1813-9.
Stanga PE, Lim JI, Hamilton P. Indocyanine green angiography in chorioretinal diseases: indications and
Printed on 4/27/2016. Page 15 of 17
interpretation: an evidence-based update. Ophthalmology. 2003;110(1):15-21; quiz 22-3. Review
Sykes SO, Bressler NM, Maguire MG, Schachat AP, Bressler SB. Detecting recurrent choroidal neovascularization.
Comparison of clinical examination with and without fluorescein angiography. Arch Ophthalmol.
1994;112(12):1561-6.
The Ophthalmic Photographers’ Society web page. (May 30, 2006). Fundamentals of fluorescein angiography
indications and uses. Available at http://www.opsweb.org/Op-Photo/Angio/FA/FA#.htm. Accessed July 21, 2006.
Vadala M, Lodato G. Cillino S. Multifocal choroiditis: indocyanine green angiographic features. Ophthalmologica.
2001;215(1):16-21.
Van Liefferinge T, Sallet G, De Laey JJ. Indocyanine green angiography in cases of inflammatory
chorioretinopathy. Bull Soc Belge Ophtalmol. 1995;257:73-81.
Watzke RC, Klein ML, Hiner CJ, Chan BK, Kraemer DF. A comparison of stereoscopic fluorescein angiography with
indocyanine videoangiography in age-related macular degeneration. Ophthalmology. 2000;107:1601-1606.
Wolf S, Kirchof B, Reim M. The Ocular Fundus: From Findings to Diagnosis. Georg Thieme Verlag. 2006:11-13.
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Revision History Information
Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History
Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a
separate and distinct row.
Revision
Revision
Reason(s) for
History
Revision History Explanation
History Date
Change
Number
R5
Update to R4
Revision Effective: 10/01/2015
• Typographical
10/01/2015 R5
Revision Explanation: H47.10 was a typographical error and
Error
should have been the span H47.11-H47.13 and H47.141H47.143 in group one. H47.10 will have a grace period until
03/14/2016 before being removed from the policy.
R4
Revision Effective: 10/01/2015
• Typographical
10/01/2015 R4
Revision Explanation: H47.10 was a typographical error and
Error
should have been the span H47.11-H47.13 and added
H47.141-H47.143 in group one.
R3
• Reconsideration
Revision Effective: 10/01/2015
10/01/2015 R3
Revision Explanation: Added H59031-H59.033 for 92235 and
Request
corrected typo in group2 paragraph.
R2
Revision Effective: 10/01/2015
• Revisions Due
Revision Explanation: Removed groups 3 and 4 since the
10/01/2015 R2
To ICD-10-CM
secondary codes are listed in the stand alone group 1
Code Changes
diagnosis list these lists were added in error. Added E10.65
and E11.65 to group one list.
R1
• Other (revenue
Revision Effective: 10/01/2015
10/01/2015 R1
code
Revision Explanation: Accepted revenue code description
description)
changes.
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Associated Documents
Attachments N/A
Related Local Coverage Documents Article(s) A52395 - Ophthalmic Angiography (Fluorescein and Indocyanine
Printed on 4/27/2016. Page 16 of 17
Green) – Supplemental Instructions
Related National Coverage Documents N/A
Public Version(s) Updated on 01/26/2016 with effective dates 10/01/2015 - N/A Updated on 01/26/2016 with
effective dates 10/01/2015 - N/A Updated on 12/16/2015 with effective dates 10/01/2015 - N/A Updated on
09/01/2015 with effective dates 10/01/2015 - N/A Updated on 06/15/2015 with effective dates 10/01/2015 - N/A
Updated on 03/17/2014 with effective dates 10/01/2015 - N/A Back to Top
Keywords
N/A Read the LCD Disclaimer Back to Top
Printed on 4/27/2016. Page 17 of 17