Coding

Illuminating truths to autofluorescence testing

The path to reimbursement for this test often leaves coders in the dark.

By Suzanne Corcoran

Coding for fundus autofluorescence testing seems to cause widespread confusion, so this month we make an attempt to provide a little clarity about this test.

Q. What is 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-Aventis)¹ or other pharmaceuticals.

The two 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, Dec. 2014,² 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, but one without a CPT code, so billers ought to use 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 the physician needs to recognize and understand. With rare exceptions, most payers, including Medicare, habitually deny claims for 92499, so the beneficiary is financially liable for payment. Since claims for FP 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. Stipulating that AF is not reimbursed is an error that resulted from a misunderstanding about the proper coding for AF. Any payment by the beneficiary for a noncovered service would represent an overpayment if the payer reimbursed the fundus photograph.

Q. Does Medicare cover FP and AF?

A. Medicare covers FP and AF if the patient presents with a complaint that leads you to perform this test or as part of management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye or as preventive medicine to screen for potential disease, then it is not covered even if the disease is identified. Also, Medicare does not cover AF if performed for an indication not cited in the local coverage policy. Check with your Medicare administrative contractor for specific coverage limitations in your area.

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 they are stored. 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.

CONCLUSION

Fundus AF imaging can provide useful information about conditions involving the health of the RPE layer. 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 FP (CPT 92250). Incorporate an interpretation and report in the chart documentation for AF and FP. Pay attention to the indications for coverage for FP in the payer’s policies. OM

REFERENCES

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.