By Cherie McNett, Academy Director of Health Policy, Michael X. Repka, MD, MBA, Academy Medical Director of Government Affairs, and Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
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Each year, the AMA updates its Current Procedural Terminology (CPT). This year, the changes most important to eye care include a brand-new code and revisions to some surgical and testing codes. A dot (◉) is used to flag new codes, and a triangle (▲) indicates that a code’s description has been revised, with underlining and strikethroughs used to identify new and deleted language, respectively.
Meet CPT Code 92242
◉ 92242 Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral.
Why a new code? This code was introduced due to a high volume of Medicare claims involving same-day use of codes 92235 Fluorescein angiography and 92240 ICG performance. (Coincidentally, payments for both codes have been cut—see “Testing Services With a Change in Description and Allowable,” below.)
Clinical vignette. A typical scenario in which you might provide the service would be a 77-year-old patient with a history of dry age-related macular degeneration who presents with subretinal blood and fluid.
Bill once per encounter. In contrast to previous billing practices, 92242 is payable once whether 1 or both eyes are tested. When only 1 eye undergoes the test, it is inappropriate to append the unique eye modifier or modifier –52, which represents a reduced service.
Medicare’s allowable is approximately $232. This will vary depending on your geographic region. Because the test will be covered by Medicare Part B, it must also be covered by Medicare Advantage plans. Commercial plans won’t necessarily add the code immediately to their list of covered testing services.
Direct supervision. The test requires direct supervision, which means that a physician must be onsite when it is performed. This doesn’t have to be the physician who ordered the test.
Correct Coding Initiative (CCI) edits that can be unbundled. CPT code 92242 is not typically payable the same day as any of the following CPT codes: 36000, 36200, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248, 36410, 76000, 76001, 77001, 77002, 92230, 92250, 93000, 93005, 93010, 93040, 93041, 93042, 96360, 96365, 96372, 96374, 96375, 96376, 96377, 99211, and 99446. But there are certain circumstances when you can bill for 92242 together with one of those other codes, even if the services are performed by the same provider for the same patient on the same day. To indicate that those circumstances apply, append a modifier to one of the codes—this is known as unbundling.
CCI edits that can’t be unbundled. Most important, 92242 has mutually exclusive edits with CPT codes 36591, 36592, 92235 FA, 92240 ICG, 96523, 99446, 99447, 99448, and 99449. Under no circumstances can you bill for 92242 and any of those 9 codes on the same day for the same patient. If you do, you will only be paid for 1 code—probably the least remunerative.
Changes to Surgery Codes
▲ CPT code 67101 Repair of retinal detachment, one or more sessions including drainage of subretinal fluid when performed; cryotherapy or diathermy, including drainage of subretinal fluid when performed
▲ CPT code 67105 Repair of retinal detachment, one or more sessions including drainage of subretinal fluid when performed; photocoagulation, including drainage of subretinal fluid, when performed
These changes eliminate references to technology that is no longer commonly used in retinal detachment repair. The phrase “one or more sessions” was removed to allow treatments to be reported separately when required.
No change to the cryotherapy code. The AMA’s 2017 CPT book incorrectly included a triangle in front of CPT code 66720 Ciliary body destruction; cryotherapy. This was a mistake; code 66720 has not changed.
Testing Services With a Change in Description and Allowable
Are testing services inherently unilateral? Ophthalmology is unusual in that it still has some testing services that are payable per eye, when there is pathology in each eye. However, CMS has recognized that bilateral testing doesn’t involve double the work—for instance, the patient is taken to a testing room and positioned only once. Consequently, whenever these tests come under payment review, they will be made inherently bilateral and “unilateral or bilateral” will be added to their descriptor. This occurred effective Jan. 1, 2017, for these 2 codes:
▲ CPT code 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
▲ CPT code 92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
As with new code 92242, it is not appropriate to append the unique eye modifier or modifier –52 representing a reduced service when only 1 eye undergoes the test.
FA and ICG payments scaled down to reflect shift from film to digital images. For years, ophthalmologists have used digital photography when performing FA and ICG, but until the recent review, payment has been based on use of film and processing of that film. Because the use of digital images is less expensive than the use of film, the Relative Value Unit (RVU) amounts associated with these services—along with their allowables—are now smaller. For example, Novitas has reduced its typical payment for FA from $117.72 (2016) to $87.80 (2017); for ICG, from $259.85 (2016) to $213.02 (2017).
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