Illuminating Autofluorescence Testing
The path to AF reimbursement often leaves coders in the dark.
SUZANNE L. CORCORAN, COE
Coding for fundus autofluorescence testing is confusing, so this month, we aim to provide some clarity about this test.
Q. What is fundus autofluorescence?
A. Autofluorescence (AF) is the term used for the natural glow that occurs in cells. Fluorophores are the chemical structures that provide the cells with these fluorescent properties; the cells glow when exposed to certain wavelengths of light. AF occurs when the fluorophore molecules absorb electromagnetic energy. The energy excites the molecules into a higher energy state and triggers the emission of light.
Fundus autofluorescence testing documents the presence of fluorophores in the human eye. AF is distinguished from the type of fluorescence that occurs from the administration of fluorescent dyes such as fluorescein or indocyanine green.
At one time, AF was considered a nuisance, but more recently it has proven helpful in imaging conditions in which the health of the retinal pigment epithelium (RPE) plays a role. AF is effective in documenting metabolic changes due to the accumulation of toxic fluorophores in the RPE layer. It is also useful for many fundus disorders, such as macular degeneration, retinal detachments, macular holes, lesions, and central serous chorioretinopathy. AF can also be useful in screening for medication toxicity related to hydroxychloroquine (Plaquenil, Sanofi, Bridgewater, NJ)1 or other pharmaceuticals.
Suzanne L. Corcoran, COE, is executive vice president and founder of Corcoran Consulting Group, San Bernardino, CA, which specializes in coding and reimbursement issues for ophthalmic practices. Her e-mail is firstname.lastname@example.org.
The most common modalities for recording AF are the standard fundus camera and confocal laser ophthalmoscopy (cSLO). The cSLO systems can acquire images at a very high rate.
Fluorescein angiography (FA) can complement AF. FA provides information about flow and the structures of the blood vessels. FA requires injection of a dye into the blood stream, while AF does not. AF provides information on certain physiological aspects of the eye, and it may also show topographical information.
Q. What code describes AF?
A. According to the AMA’s publication, CPT Assistant, December 2014, CPT code 92250 (Fundus photography with interpretation and report) best describes AF as part of a series of fundus images or as a stand-alone service. Some have suggested that AF is a separate and distinct service, and suggest CPT code 92499 (unlisted ophthalmological service or procedure) to describe it. This clarification in CPT Assistant removes any doubt about coding for AF and identifies it as an incidental part of concurrent fundus photography (FP).
Using CPT code 92499 to report AF has significant consequences that need to be understood. With rare exceptions, most payers, including Medicare, habitually deny claims for 92499, so the beneficiary is financially liable for payment. Since claims for fundus photography are reimbursed for a wide variety of pathology in the fundus, and AF is an incidental part of fundus photography, the beneficiary is only liable for the usual deductible and copayments for covered indications.
Q. Does Medicare cover FP and AF?
A. Yes, when the patient presents with a complaint that leads you to perform this test, or as part of the management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then it is not covered even if the disease is identified. Also, AF is not covered if performed for an indication that is not cited in the local coverage policy. Since AF is considered an incidental aspect of FP, check with your Medicare administrative contractor (MAC) for specific coverage limitations regarding FP in your area.
Q. What does Medicare allow for FP?
A. CPT 92250 is defined as bilateral, so reimbursement is for both eyes. The first quarter 2015 national Medicare Physician Fee Schedule allowable is $79.38. Of this amount, $55.06 is assigned to the technical component and $24.32 is the value of the professional component (ie, interpretation). These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.
92250 is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when the provider performs more than one test on the same day.
Q. Is FP bundled with other tests or services?
A. Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92250 is bundled with ICG (92240) and mutually exclusive with scanning computerized ophthalmic diagnostic imaging of the posterior segment (92133, 92134). A technician exam (99211) is bundled with this and other tests.
Q. What documentation is needed to support the test interpretation?
A. Documentation in the medical record is crucial when performing any service, including AF. The patient’s chart must include the photographs or digital images, or indicate where these are stored. Further, an order is required with the medical rationale for testing.
Within CPT, the description of 92250 also includes the phrase “with interpretation and report.” This phrase establishes a higher standard of chart documentation for fundus photography than might otherwise apply to a diagnostic test without this stipulation.
Use a form or stamp to give structure to test interpretations; remind physicians to make complete notes, and remind them as well that signing an image does not constitute a valid interpretation. Test interpretations require more documentation than “normal” or “stable.” A test interpretation should discuss what the test shows, what it means, including a comparative analysis, and what — if any — treatment is required.
In addition to the photos or proof that digital images exist, the chart should contain:
• an order for the test with medical rationale
• the date of the test
• the reliability of the test (eg, cloudy due to cataract)
• the test findings (eg, hemorrhage)
• a diagnosis (if possible)
• the impact on treatment and prognosis
• the signature of the physician
Q. Must the physician be present while the test is performed?
A. No. Under Medicare program standards, this test needs only general supervision. This means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required while the test is being performed.
Fundus AF imaging can provide useful information in conditions where the health of the RPE layer is involved. Follow the coding instructions in the December 2014, issue of CPT Assistant. Do not separately report AF on claims for reimbursement; AF is an incidental part of concurrent fundus photography (CPT 92250).
Incorporate an interpretation and report in the chart documentation for AF and fundus photography. Pay attention to the indications for coverage for fundus photography in the payer’s policies. RP
1. Stewart A. Nuts and Bolts of Fundus Autofluorescence Imaging. Available at: http://www.aao.org/publication/eyenet/201209/retina.cfm. Accessed Dec. 31, 2014.