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Date Printed: August 18, 2017: 07:59 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92000-28

Original Effective Date: 05/15/15

Reviewed: 04/27/17

Revised: 05/15/17

Next Review: 04/26/18

Subject: Electroretinography

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

The retina is the light-sensitive layer of tissue at the back of the inner eye. It is composed of rod and cone cells in the photoreceptive layer of tissue. Images come through the eye's lens and are focused on the retina. The retina then converts these images to electric signals and sends them via the optic nerve to the brain. The macula is the yellow oval spot at the center of the retina (back of the eye) that contains blood vessels and nerve fibers. It is primarily for central and color vision. The remaining retina is primarily for peripheral and night vision.

The global or full field electroretinogram (ERG) is a test used to assess the status of the retina in eye diseases. The ERG is conducted by stimulating the eye with a bright light source such as a flash produced by LEDs or a strobe lamp. The flash of light elicits a biphasic waveform recordable at the cornea. The two components that are most often measured are the a- and b-waves. A-waves are the initial corneal-negative deflection, derived from the cones and rods of the outer photoreceptor layers. B-waves are corneal-positive deflection; derived from the inner retina, predominantly Muller and ON-bipolar cells.

A limitation of the traditional global or full-field ERG is that the recording is a massed potential from the whole retina. Unless 20% or more of the retina is affected with a diseased state the ERGs are usually normal. Multi-focal electroretinography (mfERG) is an advanced form of ERG in that it produces images with higher resolution than ERG. The mathematical sequences (called binary m-sequences) were adapted to create a program that can extract hundreds of focal ERGs from a single electrical signal. This system allows assessment of ERG activity in small areas of retina.

POSITION STATEMENT:

Full field electroretinography (ERG) (92275) meets the definition of medical necessity for the following:

• To detect loss of retinal function, OR

• To distinguish between retinal lesions and optic nerve lesions

Multi-focal Electroretinography (mfERG) meets the definition of medical necessity:

• To detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity

Electroretinography (ERG) and multi-focal electroretinography (mfERG) are considered experimental or investigational for all other conditions. The data in published medical literature are inadequate to permit scientific conclusions on long-term and net health outcomes for conditions not listed above.

BILLING/CODING INFORMATION:

CPT Coding

92275

Electroretinography with interpretation and report

NOTE: There is no specific CPT code for multifocal electroretinography (mfERG).

ICD-10 Diagnoses Codes That Support Medical Necessity

A18.53

Tuberculous chorioretinitis

E08.311-E08.39

Diabetes mellitus due to underlying condition with ophthalmic complications

E09.311-E09.39

Drug or chemical induced diabetes mellitus with ophthalmic complications

E10.311-E10.39

Type 1 diabetes mellitus with ophthalmic complications

E11.311-E11.39

Type 2 diabetes mellitus with ophthalmic complications

E13.311-E13.39

Other specified diabetes mellitus with ophthalmic complications

G45.3

Amaurosis fugax

H30.001-H30.149

Chorioretinal inflammation

H30.20-H30.23

Posterior cyclitis

H30.811-H30.93

Harada's disease; other chorioretinal inflammations

H31.001-H31.429

Chorioretinal scars

H33.001-H33.119

Retinal detachment

H33.191-H33.8

Retinoschisis and retinal cysts; other retinal attachments

H34.00-H34.9

Retinal artery occlusion; retinal vein occlusions

H35.00-H35.89

Retinopathy; retinal micro-aneurysms; retinal vasculitis

H36

Retinal disorders in diseases classified elsewhere

H40.1110 – H40.1194

Primary open-angle glaucoma, staged

H46.00-H46.9

Optic papillitis

H47.011-H47.399

Ischemic optic neuropathy; optic nerve hemorrhage; other disorders of optic disc

T37.2X1A

Poisoning by antimalarials and drugs acting on other blood protozoa, accidental (unintentional), initial encounter

T37.2X2A

Poisoning by antimalarials and drugs acting on other blood protozoa, intentional self-harm, initial encounter

T37.2X3A

Poisoning by antimalarials and drugs acting on other blood protozoa, assault, initial encounter

T37.2X4A

Poisoning by antimalarials and drugs acting on other blood protozoa, undetermined, initial encounter

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline revised date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Scanning Computerized Ophthalmic Diagnostic Imaging, 01-92000-17

OTHER:

None applicable.

REFERENCES:

  1. Abdelkader M. Multifocal electroretinogram in diabetic subjects. Saudi J Ophthalmol. 2013 Apr;27(2):87-96.
  2. American Academy of Ophthalmology EyeWiki™. Electroretinogram. January 20, 2015. Accessed at http://eyewiki.aao.org/Electroretinogram.
  3. American Academy of Ophthalmology. Hydroxychloroquine-Induced Retinal Toxicity. Ophthalmic Pearls: Retina. June 2011.
  4. Azarmina M. Full-Field versus Multifocal Electroretinography. J Ophthalmic Vis Res. 2013 Jul;8(3):191-2.
  5. Azarmina M, Soheilian M, Ahmadieh H, Azarmina H. Electroretinogram changes in the sound eye of subjects with unilateral necrotizing herpetic retinitis. J Ophthalmic Vis Res. 2014 Apr;9(2):195-203.
  6. Creel, DJ. The Electroretinogram and Electro-oculogram: Clinical Applications. Webvision. The Organization of the Retina and Visual System. Accessed at http://webvision.med.utah.edu/book/electrophysiology/the-electroretinogram-clinical-applications/.
  7. Dettoraki M, Moschos MM. The Role of Multifocal Electroretinography in the Assessment of Drug-Induced Retinopathy: A Review of the Literature. Ophthalmic Res. 2016;56(4):169-177.
  8. Fernandes AG, et al. Full-field electroretinogram recorded with skin electrodes in normal adults. Arq Bras Oftalmol. 2016 Nov-Dec;79(6):390-394.
  9. International Society for Clinical Electrophysiology of Vision. ISCEV standard for clinical multifocal electroretinography (mfERG) (2011 edition). Doc Ophthalmol (2012) 124:1–13.
  10. Jansson RW, Raeder MB, Krohn J. Photopic full-field electroretinography and optical coherence tomography in type 1 diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol. 2015 Jul;253(7):989-97.
  11. Kirkiewicz M, Lubiński W, Penkala K. Photopic negative response of full-field electroretinography in patients with different stages of glaucomatous optic neuropathy. Doc Ophthalmol. 2016; 132: 57–65.
  12. Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler WF (2011). Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology, 118(2), 415-422.
  13. MedlinePlus Health Information. Macula. 10/22/11. Copyright 1997-2015, A.D.A.M., Inc. Accessed at http://www.nlm.nih.gov/medlineplus/ency/imagepages/9608.htm.
  14. MedlinePlus Health Information. Retina. 04/18/13. Copyright 1997-2015, A.D.A.M., Inc. Accessed at http://www.nlm.nih.gov/medlineplus/ency/article/002291.htm.
  15. Renard D, Rubli E, Voide N, Borruat FX, Rothuizen LE. Spectrum of digoxin-induced ocular toxicity: a case report and literature review. BMC Res Notes. 2015 Aug 23;8:368.
  16. Rossi S, et al. Functional improvement assessed by multifocal electroretinogram after Ocriplasmin treatment for vitreomacular traction. BMC Ophthalmol. 2016 Jul 18;16:110.
  17. Tehrani NM, et al. Multifocal Electroretinogram in Diabetic Macular Edema; Correlation with Visual Acuity and Optical Coherence Tomography. J Ophthalmic Vis Res. 2015 Apr-Jun;10(2):165-71.
  18. Tibbetts MD, Reichel E, Witkin AJ. Vision Loss After Intravitreal Ocriplasmin: Correlation of Spectral-Domain Optical Coherence Tomography and Electroretinography. JAMA Ophthalmol. 2014;132(4):487-490.
  19. Tiryaki Demir S, et al. Comparison of Pattern Electroretinography and Optical Coherence Tomography Parameters in Patients with Primary Open-Angle Glaucoma and Ocular Hypertension. Turk J Ophthalmol. 2015 Dec;45(6):229-234.
  20. Tzekov R, Madow B. Visual Electrodiagnostic Testing in Birdshot Chorioretinopathy. J Ophthalmol. 2015;2015:680215.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/27/17.

GUIDELINE UPDATE INFORMATION:

05/15/15

New Medical Coverage Guideline.

11/01/15

Revision: ICD-9 Codes deleted.

04/15/16

Scheduled review. Maintained position statement. Updated references.

10/01/16

ICD-10 coding update: added codes H40.1110 – H40.1194.

05/15/17

Scheduled review. Position statement maintained. Guideline reformatted. Updated references.

Date Printed: August 18, 2017: 07:59 PM