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Ophthalmology Coding Alert

Document Medical Necessity to Bill Angiography Bilaterally

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 [...]

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