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This leaflet has been produced to give you general information about having a Fluorescein and/or Indocyanine green angiogram. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.
A fluorescein angiogram is a test that provides information about problems at the back of the eye. It involves the injection of a special yellow dye called fluorescein into a vein in your hand or arm which then travels round your body and takes only a few seconds to reach the blood vessels at the back of your eye. An ophthalmic medical photographer takes a series of photographs as the dye passes through the blood vessels in your retina (light sensitive lining at the back of your eye) at timed intervals up to a 15 minute period. The fluorescein dye highlights these blood vessels and this helps with their assessment. It may show abnormalities such as blood leaking from the vessels or swelling at the back of the eye.
Indocyanine green (ICG) angiogram is a test which can provide further information about problems at the back of the eye by photographing the flow of blood through it. ICG dye shows up under infrared light after injection into a vein and the photographer will take a series of photographs. These photographs are taken at timed intervals up to a 30 minute period and provide information about the choroid (blood vessel layer) which lies underneath the retina. No X-rays or radioactive materials are used.
These tests are used to help the doctor determine the condition of the blood circulation in the retina at the back of your eye. You may need one or both tests. If the doctor requests both tests, this can be done at the same time.
There are many eye conditions where these tests may be performed to aid a diagnosis but the most common indications are in eye conditions such as:
Everyone having a Fluorescein angiogram will have some mild side effects which do not require treatment. They will resolve and leave no lasting complications.
The Fluorescein dye will give your skin a slight yellow tinge and your urine will be bright yellow for 1 or 2 days. ICG dye does not have this effect.
Some people experience this when the dye is injected. If this happens, try and take some deep breaths as it only lasts for a few seconds and will wear off quickly.
Sometimes as the dye is being injected it can leak into the surrounding tissue and this can be very painful. This can take a few days to resolve and you will be advised to put cold compresses onto the area.
An itching sensation, may occur, usually within 30 minutes of the injection.
Patients with diabetes are advised that the dye may interfere with blood and urine glucose monitoring, you may have false higher than normal glucose readings for a few days.
Moderate reactions: are also not permanent, but some form of medical treatment is required to resolve them.
IT IS IMPORTANT TO STRESS THE ABOVE ARE RARE
Severe reactions have been reported on rare occasions, including strokes, heart attacks, severe allergic reactions and even fatalities. The reported incidence of death is 1 in 200,000 cases following a fluorescein angiogram and 1 in every 300,000 cases following an ICG test.
Yes, you must take all prescribed medication as normal before coming to the department and please remember to bring a list of your prescribed medications.
Yes, you do not have to fast prior to the procedure and you can eat and drink as normal. If you are a diabetic, clinic visits can be lengthy and it is advisable that if you need to eat whilst at the outpatients then bring a snack with you. Food and drinks are not provided in the outpatients department.
A specially trained nurse performs the test, along with an Ophthalmic Medical Photographer who will take the photographs.
It is important to tell the nurse if you: know of any allergies to medicines, food or animals.
Please bring with you a list of any tablets or medicines you are currently taking.
If you use asthma inhalers or GTN (Glyceryl trinitrate) spray, please bring these with you.
There are several stages to the test.
The drops will cause some blurring of vision and may last up to 12 hours. For this reason, you are advised not to drive on this day. The flash from the camera dazzles you for about 10 minutes.
Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Ophthalmology Department on 01482816658.
General Advice and Consent
Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.
Consent to treatment
Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.
The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:
- you must be able to give your consent
- you must be given enough information to enable you to make a decision
- you must be acting under your own free will and not under the strong influence of another person
Information about you
We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.
We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.
Article Text
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34175 Ophthalmic Angiography (Fluorescein and Indocyanine Green).
General Guidelines for Claims submitted to Part A or Part B MAC:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Documentation Requirements
The patient’s medical record should include but is not limited to:
The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
Relevant medical history
Results of pertinent tests/procedures
Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
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 medical necessity must be documented in the medical record for each eye.
Documentation, including photos, must be available to Medicare upon request.
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.
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.
For claims submitted to the Part B MAC:
CPT code 92235 can be billed in place of service, office (11), ASC, by physician only and not by ASC (24), and independent clinic (49) for the global service or for the technical component (modifier TC). The technical component is also payable in a federally qualified health center (50) and rural health clinic (72.)
The professional component, CPT code 92235-26, can be billed in places of service: office (11), inpatient hospital (21), outpatient hospital (22), ASC, by physician only and not by ASC (24), and independent clinic (49).
CPT code 92240 can be billed in office (11), ASC, by physician only and not by ASC (24), and independent clinic (49) for the global service or the technical component (modifier TC). The technical component is also payable in a federally qualified health center (50) and rural health clinic (72.)
The professional component, CPT code 92240-26, can be billed in office (11), inpatient hospital (21), outpatient hospital (22), ASC, by physician only and not by ASC (24), and independent clinic (49).
These procedures are reimbursed on a unilateral basis. Modifier RT or LT must be used if one eye is being tested. If both eyes are being tested, modifier 50 must be reported.
CPT codes 92235 and 92240 are all-inclusive. They each include any setup, insertion of intravenous line, injection, cost of dye and the development of the images.
An office visit may be reported separately on the same day as fluorescein and ICG services if additional significant and separately identifiable service is rendered.
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
For claims submitted to the Part A MAC:
Hospital Inpatient Claims:
Hospital Outpatient 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.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, 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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