92240

Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

Current Procedural Terminology (CPT) code 92240 represents Indocyanine-green (ICG) angiography, an advanced, highly specialized ophthalmic diagnostic imaging technique utilized predominantly for the precise visualization and evaluation of the choroidal circulation. The choroid is the vascular layer of the eye situated between the retina and the sclera, supplying oxygen and vital nutrients to the outer layers of the retina, including the photoreceptors. While standard fluorescein angiography (FA) is highly effective for delineating the retinal vasculature, its utility is notably limited when assessing the deeper choroidal vasculature due to the blockage of visible fluorescence by the retinal pigment epithelium (RPE), macular xanthophyll pigment, and any present subretinal hemorrhage or exudate. Furthermore, fluorescein molecules are relatively small and rapidly leak from the fenestrated choriocapillaris, obscuring detailed anatomical features. In stark contrast, indocyanine green is a specialized water-soluble tricarbocyanine dye that strongly absorbs and emits light in the near-infrared spectrum. This near-infrared energy penetrates pigmented layers, such as the RPE, melanin, and even thin layers of blood or lipid exudates, far more efficiently than the visible light utilized in FA. Additionally, upon intravenous administration, indocyanine green binds heavily (up to 98 percent) to plasma proteins, predominantly globulins and lipoproteins. This extensive macromolecular binding significantly restricts the dye from diffusing out of the highly fenestrated choroidal capillaries, thereby enabling a distinct, high-contrast, and dynamic angiographic visualization of the choroidal vascular network. The procedure encoded by 92240 encompasses the intravenous injection of the indocyanine-green dye, followed immediately by rapid, multiframe digital imaging using a fundus camera equipped with specific infrared filters. These continuous, sequential images are captured over a prolonged period, typically segmented into early, mid, and late phases that can extend up to thirty or forty minutes to observe dye transit, vascular filling, and any abnormal localized hyperfluorescence or hypofluorescence. The comprehensive service includes not only the technical acquisition of these advanced images but also the mandatory, detailed interpretation and formal written report generated by the evaluating physician. Clinical scenarios necessitating 92240 frequently involve complex retinal and choroidal pathologies such as occult choroidal neovascularization, polypoidal choroidal vasculopathy, central serous chorioretinopathy, choroidal hemangiomas, and various forms of posterior uveitis. It is crucial to note that this code is defined as inherently unilateral or bilateral, meaning it is reported only once per patient encounter regardless of whether one or both eyes are examined.

Clinical Indications

  • Age-related macular degeneration (AMD) with suspected occult choroidal neovascularization (CNV).
  • Polypoidal choroidal vasculopathy (PCV), to identify branching vascular networks and polyps.
  • Central serous chorioretinopathy (CSCR) or idiopathic central serous retinopathy, to map choroidal hyperpermeability.
  • Choroidal hemangiomas, melanomas, or other intraocular tumors and masses.
  • Posterior uveitis and inflammatory choroidal conditions such as birdshot chorioretinopathy, Vogt-Koyanagi-Harada (VKH) disease, and multifocal choroiditis.
  • Evaluation of atypical or complex retinal pigment epithelial detachments (PED).

Procedure Steps

  1. Perform a comprehensive patient assessment to establish indications and rule out contraindications, specifically confirming the absence of severe allergies to iodine or shellfish, as ICG dye contains iodine.
  2. Administer topical mydriatic eye drops to dilate the patient's pupils adequately for high-quality fundus imaging.
  3. Establish reliable peripheral intravenous (IV) access, typically in the antecubital vein of the arm.
  4. Position the patient comfortably at a specialized digital fundus camera equipped with near-infrared illumination and appropriate excitation/barrier filters for indocyanine green.
  5. Administer the indocyanine-green dye (usually 25 to 50 mg reconstituted in aqueous solvent) via the established IV line as a rapid bolus, immediately followed by a saline flush.
  6. Capture a rapid sequence of high-resolution, multiframe digital images as the dye enters the choroidal and retinal circulations.
  7. Continue capturing images sequentially through the early, mid, and late angiographic phases, which may require imaging for up to 30 to 40 minutes post-injection to detect slow-filling lesions or late-phase hyperfluorescence.
  8. Continuously monitor the patient for adverse reactions, nausea, or anaphylaxis during the injection and throughout the observation period.
  9. Remove the IV access and provide post-procedural care instructions to the patient.
  10. The physician performs a detailed review of the multiframe images, interprets the choroidal hemodynamics and structural findings, and generates a formal, signed written report.

Coding Guidelines

  • CPT code 92240 is inherently unilateral or bilateral; do not append modifier 50 or anatomical modifiers (RT/LT) if both eyes are imaged. The code is billed only once per patient encounter.
  • If both fluorescein angiography and indocyanine-green angiography are performed on the same patient during the same encounter, do not report 92235 and 92240 together. Instead, report the combined CPT code 92242.
  • The technical work of multiframe imaging, the intravenous injection procedure, and the physician's interpretation and report are all bundled into 92240 and should not be billed separately.
  • Depending on specific payer guidelines, the supply of the indocyanine-green dye may be billed separately using the appropriate HCPCS Level II code (e.g., J2560 for Injection, indocyanine green, 10 mg).
  • A formal, documented interpretation and report by the physician must be present in the medical record to substantiate billing this code. Brief notes such as 'normal ICG' are insufficient; a full description of findings is required.

Associated ICD-10 Codes