92235

🧬CPT Code 92235 - Fluorescein Angiography

Code Classification

• CPT Code: 92235
• Description: Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
• Category: Medicine Procedures
• Section: Ophthalmology (92002-92499)
• Subsection: Special Ophthalmological Services (92225-92287)
• Type: Diagnostic Procedure
• Global Period: 0 days (no global period)
• Bilateral Indicator: Included in code (unilateral OR bilateral - same code)

Procedure Description

Fluorescein angiography (FA) is a diagnostic imaging procedure used to evaluate the retinal and choroidal vasculature by photographing the passage of intravenously injected fluorescein dye through the blood vessels of the eye. This test is essential for diagnosing and managing various retinal and choroidal vascular disorders.

Clinical Purpose

Fluorescein angiography is used to:

• Evaluate retinal blood flow and vascular integrity
• Identify retinal vascular leakage, occlusion, or neovascularization
• Assess choroidal circulation abnormalities
• Diagnose and monitor diabetic retinopathy
• Evaluate age-related macular degeneration (AMD)
• Identify retinal vein/artery occlusions
• Assess inflammatory conditions (uveitis, vasculitis)
• Guide treatment decisions (laser, anti-VEGF injections)
• Monitor treatment response
• Detect occult choroidal neovascular membranes

Procedure Technique

Pre-Procedure:

1. Obtain informed consent (discuss risks including nausea, vomiting, rare anaphylaxis)
2. Dilate pupils with mydriatic agents
3. Document baseline color fundus photographs
4. Establish IV access (typically antecubital vein)
5. Position patient at fundus camera
6. Test camera focus and alignment

During Procedure:

1. Injection Phase: Inject 5mL of 10% sodium fluorescein dye rapidly via IV
2. Early Phase Imaging (0-30 seconds):
   • Choroidal filling
   • Arterial phase
   • Arteriovenous phase
3. Mid-Phase Imaging (30 seconds - 5 minutes):
   • Venous phase
   • Peak fluorescence
   • Early recirculation
4. Late Phase Imaging (5-10 minutes):
   • Venous emptying
   • Staining patterns
   • Leakage identification
5. Extended Views (if indicated): Up to 20-30 minutes for late leakage

Post-Procedure:

• Remove IV access
• Monitor for adverse reactions (15-30 minutes)
• Advise patient about yellow skin/urine discoloration (24-48 hours)
• Provide emergency contact information

Image Interpretation: The ophthalmologist reviews the multiframe sequence to identify:

• Vascular filling patterns and timing
• Areas of hyperfluorescence (leakage, staining, window defects)
• Areas of hypofluorescence (blockage, vascular occlusion)
• Neovascularization
• Microaneurysms
• Vascular abnormalities
• Choroidal abnormalities

What’s Included in CPT 92235

The code includes ALL of the following:

• Pre-procedure patient preparation and consent
• Establishment of IV access
• Injection of fluorescein dye
• Multiframe imaging (sequential photographs throughout all phases)
• Both eyes if bilateral imaging is performed (NO modifier needed)
• Image review and interpretation by physician
• Written report with findings and clinical correlation
• Any repeat imaging during same session
• Post-procedure monitoring for immediate complications

Important: 92235 is a unilateral OR bilateral code - you report it only ONCE regardless of whether one or both eyes are imaged.

wRVU (Work Relative Value Units)

2025 Medicare Physician Fee Schedule Values:

Facility Setting (Hospital, ASC)

• Work RVU: 1.18
• Practice Expense RVU: 5.96
• Malpractice RVU: 0.11
• Total RVU: 7.25
• National Payment (2025): ~$241.89(basedonconversionfactorof$33.37)

Non-Facility Setting (Office, Clinic)

• Work RVU: 1.18 (same)
• Practice Expense RVU: 20.44 (significantly higher - includes equipment)
• Malpractice RVU: 0.11
• Total RVU: 21.73
• National Payment (2025): ~$725.23

Key Points:

• Work RVU represents physician effort, time, and skill
• Practice expense is much higher in non-facility setting due to:
  • Expensive fundus camera equipment ($30,000-$100,000+)
  • Fluorescein dye and supplies
  • Staff time for imaging
  • Equipment maintenance
• Geographic adjustment (GPCI) varies by location
• Actual payment varies by Medicare contractor and locality

Relative Value Breakdown

• Pre-service time: 3 minutes
• Intra-service time: 20 minutes (includes imaging and immediate review)
• Post-service time: 5 minutes
• Total physician time: 28 minutes
• Intensity/Complexity: Moderate

Assistant Surgeon Information

Assistant Surgeon Payability: NOT APPLICABLE

• Assistant Surgeon: Not payable (this is a diagnostic imaging procedure)
• Co-surgeon (Modifier 62): Not applicable
• Team Surgeon (Modifier 66): Not applicable
• Surgical Assistant (Modifier 80, 81, 82): Not applicable

Rationale: Fluorescein angiography is a diagnostic imaging procedure performed by a single physician or qualified technician under physician supervision. No surgical assistants are required or payable for this service.

Who Can Perform:

• Ophthalmologist (physician)
• Optometrist (in some states, with appropriate credentials)
• Certified ophthalmic photographer (under physician supervision for technical component)

Professional vs Technical Component:

• 92235: Global code (professional + technical)
• 92235-TC: Technical component only (imaging)
• 92235-26: Professional component only (interpretation and report)

HCC Information

HCC Status: NOT APPLICABLE

• Important Note: HCC (Hierarchical Condition Category) codes apply only to ICD-10 diagnosis codes, NOT to CPT procedure codes
• CPT 92235 is a procedure code used for billing services rendered
• The diagnosis codes used to justify this procedure may map to HCC categories

Relevant Diagnosis Codes That May Map to HCC:

HCC 19 - Diabetes with Acute Complications:

• E11.351- (Type 2 diabetes with proliferative diabetic retinopathy)
• E11.37X- (Type 2 diabetes with diabetic macular edema)

HCC 18 - Diabetes with Chronic Complications:

• E11.319 (Type 2 diabetes with unspecified diabetic retinopathy without macular edema)
• E11.329 (Type 2 diabetes with mild nonproliferative diabetic retinopathy without macular edema)

HCC 124 - Exudative Macular Degeneration:

• H35.32 (Exudative age-related macular degeneration)

Non-HCC Conditions Requiring FA:

• H34.81- (Central retinal vein occlusion)
• H34.23- (Central retinal artery occlusion)
• H35.50 (Unspecified hereditary retinal dystrophy)

MS-DRG Information

MS-DRG: NOT DIRECTLY APPLICABLE

• Important: CPT codes do not directly determine MS-DRG assignment
• MS-DRGs are assigned based on principal diagnosis, secondary diagnoses, procedures, and patient characteristics
• Fluorescein angiography is typically an outpatient diagnostic procedure
• Rarely results in inpatient admission

Scenarios Where MS-DRG May Apply:

If Patient Admitted for Underlying Condition:

• MS-DRG 124: Other Disorders of the Eye with MCC
• MS-DRG 125: Other Disorders of the Eye without MCC

Note

Example: Patient admitted for severe diabetic retinopathy with complications undergoes FA during inpatient stay. The DRG is determined by the diagnosis codes and overall case complexity, not by the FA procedure itself.

Outpatient Setting (Most Common):

• APC 5492: Level 2 Anterior Segment Eye Procedures (varies)
• Fluorescein angiography is typically performed as an outpatient procedure in:
  • Ophthalmologist’s office
  • Hospital outpatient department (HOPD)
  • Ambulatory surgery center (rarely)
  • Optometry clinic

Payment Structure:

• Medicare Outpatient: Paid under OPPS (Outpatient Prospective Payment System)
• Physician Office: Paid under Medicare Physician Fee Schedule
• Commercial Insurance: Contract-dependent rates

Code Tree / Hierarchy

CPT Section Structure

Medicine (90281-99607)
└── Ophthalmology (92002-92499)
    └── Special Ophthalmological Services (92225-92287)
        ├── 92225: Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma)
        ├── 92226: Ophthalmoscopy, extended, with drawing and scleral depression
        ├── 92227: Remote imaging for retinal disease with interpretation and report, unilateral or bilateral
        ├── 92228: Remote imaging for retinal disease, technical component only
        ├── 92230: Fluorescein angioscopy with interpretation and report
        ├── 92235: Fluorescein angiography (includes multiframe imaging) ◄ THIS CODE
        ├── 92240: Indocyanine-green angiography (includes multiframe imaging)
        ├── 92242: Fluorescein angiography and indocyanine-green angiography (performed at same session)
        ├── 92250: Fundus photography with interpretation and report
        ├── 92260: Ophthalmodynamometry
        └── 92265: Needle oculoelectromyography, one or more extraocular muscles

Related Imaging Codes

92235: Fluorescein angiography ◄ THIS CODE
├── 92235-26: Professional component (interpretation only)
├── 92235-TC: Technical component (imaging only)
├── 92240: Indocyanine-green angiography (ICG) - different dye, choroidal focus
├── 92242: FA + ICG combined (same session)
└── 92250: Fundus photography (no dye injection)

Includes

CPT 92235 INCLUDES all of the following services:

Technical Services

• Patient positioning and preparation
• Pupil dilation (if needed for imaging)
• IV access establishment
• Fluorescein dye injection (5mL of 10% sodium fluorescein)
• Camera setup and calibration
• Multiframe imaging (sequential photographs throughout all phases):
  • Early phase (choroidal filling, arterial, arteriovenous)
  • Mid-phase (venous, peak fluorescence)
  • Late phase (5-10 minutes)
  • Extended late views if clinically indicated
• Both eyes if bilateral imaging performed
• Image processing and quality control
• Post-procedure monitoring
• Supply costs (dye, IV catheter, etc.)

Professional Services

• Review of all images from all phases
• Identification of normal and abnormal findings
• Clinical correlation with patient history
• Interpretation of fluorescence patterns
• Diagnosis and recommendations
• Written report with:
  • Indication for study
  • Quality of study
  • Findings in both arterial and venous phases
  • Areas of hyperfluorescence and hypofluorescence
  • Clinical significance
  • Comparison to prior studies (if available)
  • Recommendations for management

Bilateral Coverage

• Both eyes: Same code (92235) - report only ONCE
• One eye: Same code (92235) - report only ONCE
• No bilateral modifier needed

Excludes

Do NOT Report 92235 With (in same session):

Mutually Exclusive Codes:

• 92230: Fluorescein angioscopy (different technique - viewing through scope, not photography)
  • This is real-time observation, not multiframe imaging

Bundled Services (Included in 92235):

• 92250: Fundus photography (color photos are pre-FA baseline, included)
• 99212-99215: E/M services on same date (unless significant separate service with modifier 25)
• 92002-92014: Eye exams same date (unless distinct service with modifier 25)

Use Different Code Instead:

• 92240: Indocyanine-green angiography (ICG) - if using ICG dye instead of fluorescein
• 92242: Combined FA + ICG - if performing both dyes in same session (report 92242, not 92235 + 92240)

Report Separately (When Appropriate):

May report in addition to 92235:

• 92227/92228: Retinal imaging with remote analysis (different modality - OCT, widefield)
• 67028: Intravitreal injection (if performed same session with modifier -51 or -59)
• 67210: Laser photocoagulation (if performed after FA, with modifier -59)
• 92201-92202: Ophthalmoscopy with drawing (if separate extended exam beyond FA)
• 99212-99215: E/M with modifier -25 if significant separately identifiable service

Different Date of Service:

• Any procedure code can be reported on different dates without restriction

Modifiers

Commonly Used Modifiers with 92235:

Component Modifiers:

• -26 (Professional Component): Use when only interpreting images taken elsewhere

  • Example: Images done at hospital, ophthalmologist interprets at office
  • Payment: Covers only interpretation (work RVU portion)

• -TC (Technical Component): Use when only performing imaging, not interpretation

  • Example: Hospital performs imaging, sends to outside ophthalmologist for reading
  • Payment: Covers only imaging and supplies

• -52 (Reduced Services): Use when procedure is partially completed

  • Example: Started FA but patient had severe reaction, study terminated
  • Requires documentation of why incomplete
  • May result in reduced payment

• -53 (Discontinued Procedure): Use when procedure stopped due to threat to patient

  • Example: Patient has anaphylactic reaction immediately after injection
  • Document reason for discontinuation
  • Payment typically 0% or negotiated

• -59 (Distinct Procedural Service): Use to unbundle when appropriate

  • Example: FA performed with same-day intravitreal injection
  • Use only when procedures are truly separate
  • Consider XE, XS, XP, XU modifiers (more specific)

Service Location Modifiers:

• -LT (Left side): NOT typically used (92235 is inherently bilateral)
• -RT (Right side): NOT typically used (92235 is inherently bilateral)
• -50 (Bilateral): NOT used (bilaterality is inherent in code)

Important: Do NOT use bilateral modifier -50 with 92235 as it already includes bilateral imaging.

Medical Necessity & Coverage

Medicare LCD (Local Coverage Determinations)

Covered Indications (Examples):

• Diabetic retinopathy (E11.3-) - monitoring and treatment planning
• Age-related macular degeneration (H35.3-) - identifying CNV
• Retinal vein occlusion (H34.81-, H34.82-) - assessing ischemia
• Retinal artery occlusion (H34.1-, H34.2-) - evaluating perfusion
• Choroidal neovascularization (H35.05-)
• Central serous chorioretinopathy (H35.71-)
• Ocular histoplasmosis (H35.02-)
• Cystoid macular edema (H35.81)
• Retinal vasculitis
• Suspected retinal vascular occlusion
• Uveitis with vascular involvement (H20.-)
• Epiretinal membrane evaluation (H35.37-)

Frequency Limitations:

• Medicare: Typically allows FA based on medical necessity, not strict frequency limits
• Commercial: May limit to 1-2 per eye per year without prior authorization
• More frequent FA may be covered for:
  • Active diabetic retinopathy requiring frequent monitoring
  • Monitoring anti-VEGF therapy response
  • Suspected recurrent CNV
  • Acute vascular events

Documentation Requirements:

1. Medical record must contain:

   • Clear indication/diagnosis requiring FA
   • Clinical question to be answered by FA
   • How FA results will affect management
   • Prior treatments and their outcomes
   • Visual acuity
   • Dilated fundus exam findings

2. Report must include:

   • All phases of angiogram interpretation
   • Specific findings with anatomic localization
   • Clinical significance of findings
   • Treatment recommendations
   • Comparison to prior studies

Non-Covered Indications (Typical):

• Routine screening without symptoms or risk factors
• Asymptomatic patient with clear media and normal fundus
• Mild cataracts without retinal pathology
• Refractive errors alone
• Dry eye syndrome
• Anterior segment conditions without retinal involvement

Coding Guidelines

Correct Coding Initiative (CCI) Edits

Column 1/Column 2 Edits (Cannot bill together):

• 92235 is Column 1 (comprehensive)
• 92250 (fundus photography) is Column 2 (bundled)
  • Cannot bill both same session without modifier 59 and documentation

Modifier Allowed: Some edits allow modifier 59 if circumstances warrant

Billing Rules

1. One Unit Per Session

• Bill 92235 × 1 (one unit) regardless of:
  • One eye or both eyes imaged
  • Number of frames taken
  • Duration of imaging
  • Whether early, mid, and late phases all performed

2. Same Day as Injection

• Can bill with 67028 (intravitreal injection) with modifier -59
• Must document separate decision-making for each procedure
• Many payers require modifier on injection code, not FA code

3. Professional vs Technical Component

• In office setting: Bill global code (92235)
• Split billing:
  • Hospital bills technical: 92235-TC
  • Physician bills professional: 92235-26
  • Total RVUs: -TC + -26 = Global

4. Incomplete Study

• If study incomplete due to patient factors (poor dilation, media opacity):
  • Still bill 92235 if images obtained and interpreted
  • Document limitations in report
• If terminated due to adverse reaction:
  • Use modifier -52 or -53
  • Document reason

5. Repeat FA Same Day

• If repeat imaging needed same day (poor quality, additional views):
  • Included in single code
  • Do NOT bill 92235 × 2
• Exception: Completely separate session for different indication (rare)

Coding Examples

Example 1: Bilateral Diabetic Retinopathy Screening

Scenario: 65-year-old patient with Type 2 diabetes and proliferative diabetic retinopathy in both eyes presents for fluorescein angiography to assess for treatment planning. Both eyes are imaged showing extensive microaneurysms, intraretinal microvascular abnormalities, and areas of capillary nonperfusion bilaterally.

Coding:

• CPT: 92235 × 1 (reported once even though bilateral)
• Diagnosis:
  • E11.3593 (Type 2 diabetes with proliferative diabetic retinopathy without macular edema, bilateral)
• Modifiers: None needed
• Place of Service: 11 (Office)
• Units: 1

Documentation Note: Report clearly states “bilateral fluorescein angiography performed” and includes findings for both right and left eyes in all phases.

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Example 2: Age-Related Macular Degeneration with CNV

Scenario: 78-year-old with sudden vision loss in right eye. Exam shows subretinal fluid. FA performed showing classic choroidal neovascular membrane in right eye. Left eye shows drusen but no CNV.

Coding:

• CPT: 92235 × 1
• Diagnosis:
  • H35.3211 (Exudative age-related macular degeneration, right eye, with active choroidal neovascularization)
  • H35.3620 (Drusen of macula, right eye)
• Modifiers: None
• Place of Service: 11 (Office)
• Units: 1

Note: Even though pathology is primarily in one eye, both eyes were imaged (standard practice), so report 92235 once.

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Example 3: Central Retinal Vein Occlusion with Same-Day Injection

Scenario: Patient with acute CRVO right eye undergoes FA to assess macular ischemia. Study shows significant areas of capillary nonperfusion. Based on FA findings, patient receives intravitreal anti-VEGF injection same session.

Coding:

• CPT:
  • 92235 (Fluorescein angiography)
  • 67028-59 (Intravitreal injection, distinct procedural service)
• Diagnosis:
  • H34.8110 (Central retinal vein occlusion, right eye, with macular edema)
• Modifiers:
  • -59 on 67028 (to show injection is separate from FA)
• Place of Service: 11 (Office)

Documentation: Must clearly show FA was performed, interpreted, decision made based on FA findings, then separate procedure (injection) performed based on those findings.

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Example 4: Professional Component Only (Split Billing)

Scenario: Patient has FA performed at hospital outpatient department. Images sent to retina specialist’s office for interpretation.

Hospital Bills:

• CPT: 92235-TC (Technical component)
• Place of Service: 22 (On-campus hospital outpatient)

Physician Bills:

• CPT: 92235-26 (Professional component)
• Place of Service: 11 (Office)
• Diagnosis: Same as hospital

Important: Only one entity bills global code. When split, hospital bills TC, physician bills 26.

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Example 5: Incomplete Study Due to Adverse Reaction

Scenario: Patient receives fluorescein injection and develops severe nausea and vomiting after early-phase images. Study terminated. Physician reviews available early images and provides limited interpretation.

Coding:

• CPT: 92235-52 (Reduced services) OR 92235-53 (Discontinued procedure)
• Diagnosis:
  • E11.3513 (Type 2 diabetes with proliferative diabetic retinopathy, bilateral)
  • T50.8X5A (Adverse effect of diagnostic agents, initial encounter)
• Modifiers:
  • -52 if physician was able to obtain some diagnostic information
  • -53 if study had to be stopped before any useful images obtained

Documentation: Must document reason for incomplete study, what images were obtained, and any interpretable findings.

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Example 6: FA After Laser Photocoagulation (Different Date)

Scenario: Patient with diabetic retinopathy received panretinal photocoagulation (PRP) 3 months ago. Returns today for follow-up FA to assess treatment response.

Coding:

• CPT: 92235
• Diagnosis:
  • E11.3593 (Type 2 diabetes with proliferative diabetic retinopathy without macular edema, bilateral)
  • Z09 (Encounter for follow-up examination after completed treatment)
• Modifiers: None
• Place of Service: 11

Note: Since laser was on different date, no modifier needed. FA is clearly a follow-up study.

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Example 7: Bilateral Uveitis Evaluation

Scenario: 35-year-old with bilateral panuveitis undergoes FA to assess retinal vasculitis and vascular leakage in both eyes.

Coding:

• CPT: 92235 × 1
• Diagnosis:
  • H44.113 (Panuveitis, bilateral)
  • H35.06 (Retinal vasculitis)
• Modifiers: None
• Place of Service: 11

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Example 8: Central Serous Chorioretinopathy

Scenario: 42-year-old male with metamorphopsia and decreased vision in left eye. Exam shows serous retinal detachment. FA performed showing focal RPE leak consistent with central serous chorioretinopathy.

Coding:

• CPT: 92235
• Diagnosis:
  • H35.712 (Central serous chorioretinopathy, left eye)
• Modifiers: None
• Place of Service: 11

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Example 9: Post-Cataract Surgery CME Evaluation

Scenario: Patient 6 weeks post-cataract surgery with persistent blurred vision. FA performed showing cystoid macular edema (Irvine-Gass syndrome).

Coding:

• CPT: 92235
• Diagnosis:
  • H59.031 (Cystoid macular edema following cataract surgery, right eye)
  • Z98.83 (Pseudophakia)
• Modifiers: None
• Place of Service: 11

Note: Postoperative CME is a valid indication for FA even though not related to primary retinal vascular disease.

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Example 10: Combined with E/M Service (Modifier 25)

Scenario: Established patient presents with new-onset floaters and vision loss. Comprehensive eye exam performed showing possible CRVO. Decision made to perform FA same visit. E/M service is significant and separately identifiable from FA.

Coding:

• CPT:
  • 92014-25 (Comprehensive eye exam, established patient, with significant separate service)
  • 92235 (Fluorescein angiography)
• Diagnosis:
  • H34.8110 (CRVO with macular edema, right eye)
  • H43.311 (Vitreous membranes and strands, right eye)
• Modifiers: -25 on E/M to show significant separate service

Documentation: Must clearly show comprehensive exam was performed BEFORE decision to do FA, that exam findings led to decision for FA, and that E/M service was beyond what is normally included in FA.

Reimbursement Information

Medicare Payment (2025 National Average)

Non-Facility (Office/Clinic):

• Payment: ~$725.23
• Patient responsibility (20% coinsurance): ~$145.05
• Medicare pays (80%): ~$580.18

Facility (Hospital Outpatient):

• Technical Component: ~$203.00
• Professional Component: ~$38.89
• Total: ~$241.89

Geographic Variation:

• New York City: ~$845.00 (office)
• Los Angeles: ~$790.00 (office)
• Rural Kansas: ~$650.00 (office)
• Rates vary by GPCI (Geographic Practice Cost Index)

Commercial Insurance

• Payment rates vary widely: $400-$1,200
• Typical negotiated rates: $600-$900
• May require prior authorization
• Frequency limits common (1-2 per year)

Denial Prevention

Common Denial Reasons:

1. Lack of medical necessity
   • Solution: Clear documentation of indication
2. Frequency limits exceeded
   • Solution: Obtain prior authorization, document medical necessity for repeat study
3. Missing or incorrect diagnosis code
   • Solution: Ensure ICD-10 code supports need for FA
4. Bundled with other services
   • Solution: Use appropriate modifiers (59, 25) when services are truly separate
5. Incomplete documentation
   • Solution: Ensure full report with all phases interpreted is in medical record

Clinical Pearls for Coders

1. One code for both eyes: Never use modifier 50 or bill 92235 × 2 for bilateral imaging. Always bill 92235 × 1 regardless of whether one or both eyes imaged.

2. Technical vs Professional split: Common in hospital settings. Hospital bills 92235-TC for performing imaging, physician bills 92235-26 for interpretation. Never bill both global codes.

3. Same-day injection: When performing intravitreal injection same day as FA:

   • Use modifier -59 on 67028 (injection code)
   • Do NOT use modifier 59 on 92235
   • Document that FA findings guided decision for injection

4. Fundus photos are included: Color fundus photographs (92250) taken as baseline before FA are considered part of FA and not separately billable.

5. Frequency: While no strict Medicare frequency limit, most commercial payers limit to 1-2 FA per year per eye without prior authorization. Document medical necessity for more frequent studies.

6. ICG vs Fluorescein:

   • 92235 = Fluorescein angiography
   • 92240 = Indocyanine-green (ICG) angiography
   • 92242 = Both performed same session
   • Do NOT bill 92235 + 92240; use 92242 instead

7. Report requirements: FA report must include interpretation of ALL phases (early, mid, late) and both eyes if bilateral. Incomplete reports may result in denial.

8. Medical necessity documentation: Chart must clearly state why FA is needed and how results will affect management. “Rule out CNV” or “assess for DME” are appropriate indications.

9. Incomplete studies: If study started but not completed:

   • Use modifier 52 if some diagnostic information obtained
   • Use modifier 53 if study discontinued before obtaining useful images
   • Document reason for incomplete study

10. Pre-authorization: Many commercial payers require PA for FA. Check before scheduling to avoid denials.

11. E/M same day: Can bill comprehensive eye exam (92004, 92014) same day as FA with modifier 25 if:

    • E/M service is significant and separately identifiable
    • E/M led to decision to perform FA
    • Documentation supports both services

12. Bilateral vs unilateral pathology: Even if disease is only in one eye, standard practice is to image both eyes for comparison. Still bill only 92235 × 1.

Safety and Complications

Common Adverse Effects (Include in Documentation)

• Nausea (5-10% of patients)
• Yellow skin discoloration (24-48 hours)
• Yellow urine (24-48 hours)
• Vasovagal reaction
• Extravasation at IV site

Serious Adverse Effects (Document and Code)

• Anaphylaxis (rare: <1:1000)
  • ICD-10: T50.8X5A (Adverse effect of diagnostic agents)
  • If severe: T78.2XXA (Anaphylactic shock)
• Cardiac events (extremely rare in patients with cardiac history)
• Respiratory distress
• Seizures (in patients with seizure disorder)

Contraindications (May Affect Coverage)

• Known allergy to fluorescein
• Pregnancy (relative contraindication - document discussion)
• Severe renal failure (controversial - fluorescein is renally excreted)

Quality Measures

MIPS (Merit-Based Incentive Payment System)

• FA quality is monitored for appropriateness
• Outcomes: Response to treatment guided by FA
• Cost: Appropriate use affects resource utilization scores

Appropriate Use Criteria

• American Academy of Ophthalmology Preferred Practice Patterns guide appropriate FA use
• Overutilization may trigger payer review
• Under-utilization may affect quality of care metrics

Related CPT Codes

Related Ophthalmology Imaging

• 92227: Remote retinal imaging with interpretation (autonomous AI-based diabetic retinopathy screening)
• 92228: Remote retinal imaging, technical component only
• 92230: Fluorescein angioscopy (real-time viewing, not photography)
• 92240: Indocyanine-green angiography (different dye, choroidal imaging)
• 92242: Combined FA + ICG (both dyes same session)
• 92250: Fundus photography (color photos, no dye)
• 92260: Ophthalmodynamometry

Optical Coherence Tomography (Often Done With FA)

• 92133: Optical coherence tomography (OCT) optic nerve
• 92134: OCT retina, one or more eyes (serial)

Treatment Procedures Often Guided by FA

• 67028: Intravitreal injection (anti-VEGF based on FA findings)
• 67210: Laser photocoagulation, one or more sessions (treatment of areas identified on FA)
• 67228: Laser photocoagulation, extensive (panretinal photocoagulation for ischemia found on FA)

Documentation Template

Sample FA Report Structure

PROCEDURE: Fluorescein Angiography
DATE: [Date]
INDICATION: [Diagnosis requiring FA]
PATIENT PREPARATION: Pupils dilated with [agents]. IV access established.
DYE INJECTION: 5mL 10% sodium fluorescein injected IV without complication.

FINDINGS:
Right Eye:
- Early Phase (0-30 sec): [Choroidal filling, arterial filling, AV phase]
- Mid Phase (30 sec - 5 min): [Venous filling, peak fluorescence]
- Late Phase (5-10 min): [Staining, leakage patterns]
- Abnormalities: [Specific findings with location]

Left Eye:
- Early Phase: [Findings]
- Mid Phase: [Findings]
- Late Phase: [Findings]
- Abnormalities: [Specific findings]

INTERPRETATION:
[Clinical significance of findings]

COMPARISON: [To prior studies if available]

IMPRESSION:
1. [Primary finding]
2. [Secondary findings]

RECOMMENDATIONS:
[Treatment plan based on FA findings]

___________________
[Physician Name]
[Date/Time]

References for Further Study

• CPT® 2025 Professional Edition
• Medicare Physician Fee Schedule (MPFS) 2025
• National Correct Coding Initiative (NCCI) Policy Manual
• American Academy of Ophthalmology Coding Guidelines
• CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 12
• Local Coverage Determinations (LCDs) for ophthalmology services

Update History

• 2025: No significant changes to code definition or RVU values
• Valid through: At least 2025
• Watch for: Annual MPFS updates each November