local coverage determination (lcd): scanning computerized

Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L33751)Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.

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First Coast Service Options, Inc. A and B MAC 09101 - MAC A J - N Florida

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LCD Information

Document Information

LCD IDL33751 LCD TitleScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) Proposed LCD in Comment PeriodN/A Source Proposed LCDDL33751 AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT codes, descriptions and other data only are copyright 2018 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Current Dental Terminology © 2018 American Dental Association. All rights reserved. Copyright © 2018, the American Hospital Association,

Original Effective DateFor services performed on or after 10/01/2015 Revision Effective DateFor services performed on or after 01/29/2019 Revision Ending DateN/A Retirement DateN/A Notice Period Start Date12/07/2017 Notice Period End Date01/24/2018

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Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected].

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for scanning computerized ophthalmic diagnostic imaging services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for scanning computerized ophthalmic diagnostic imaging services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: IOM Citations

CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual

Chapter 1, Part 1 Sections 80.2 Photodynamic Therapy (OPT), 80.2.1 Ocular Photodynamic Therapy (OPT), 80.3 Photosensitive Drugs, 80.3.1 Verteporfin, 80.6 Intraocular Photography and 80.9 Computer Enhanced Perimetry

Chapter 1, Part 2 Section 140.5 Laser Procedures

Chapter 1, Part 4 Section 220.1 Computed Tomography (CT)

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CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure codes

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CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4•

CMS IOM Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Correct Coding Initiative

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Other

National Correct Coding Initiative Coding Policy Manual for Medicare Services, Chapter XI Medicine Evaluation and Management Services CPT Codes 90000 - 99999, Section G Ophthalmology, Effective January 1, 2017

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Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

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Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.•Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

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Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Glaucoma

Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Scanning computerized ophthalmic diagnostic imaging (SCODI) allows for early detection of glaucomatous damage to the nerve fiber layer or optic nerve of the eye. It is the goal of these diagnostic imaging tests to discriminate among patients with normal IOP who have glaucoma, patients with elevated IOP who have glaucoma, and patients with elevated IOP who do not have glaucoma. These tests can also provide precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of follow-up exams than visual field and/or disc photos. This can allow earlier and more efficient treatment of the disease process. The severity of glaucoma damage can be estimated as mild, moderate, severe, or indeterminate.

Retinal Disorders

Retinal disorders are the most common causes of severe and permanent vision loss. SCODI is a valuable tool for the evaluation and treatment of patients with retinal disease, especially macular abnormalities. SCODI is able to detail the microscopic anatomy of the retina and the vitreo-retinal interface. SCODI is useful to measure the effectiveness of therapy, in determining the need for ongoing therapy or cessation of therapy.

The retina is a complex tissue in the back of the eye that contains specialized photoreceptor cells called rods and

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cones. The photoreceptors connect to a network of nerve cells for the local processing of visual information. This information is sent to the brain for decoding into a visual image. The adjacent retinal pigment epithelium (RPE) supports many of the retina’s metabolic functions.

The retina is susceptible to a variety of diseases, including age-related macular degeneration (AMD), diabetic retinopathy (DR), retinitis pigmentosa (RP) and other inherited retinal degenerations, uveitis, retinal detachment, and eye cancers. Each of these can lead to visual loss or complete blindness.

The leading cause of visual loss among elderly persons is AMD, which has an increasingly important social and economic impact in the United States. As the size of the elderly population increases in this country, AMD will become a more prevalent cause of blindness than both DR and glaucoma combined.

DR is also a major cause of blindness. In the proliferative stage of the disease, newly formed, abnormal blood vessels can break through the retinal surface and hemorrhage into the normally transparent, gelatin-like vitreous in the middle of the eye. Scar tissue may subsequently form and pull the retina away from the back of the eye, causing a retinal detachment to occur.

Rare inherited retinal degenerations, typified by RP, result in the destruction of photoreceptor cells and the RPE.

Clinical evidence has shown that long-term use of chloroquine (CQ) and/or hydroxychloroquine (HCQ) can lead to irreversible retinal toxicity. SCODI may be indicated to provide monitoring of patients for the development of retinopathy during long-term therapy.

SCODI Techniques

There are several forms of SCODI tests that currently exist. SCODI testing includes scanning laser polarimetry, optical coherence tomography (OCT), and confocal scanning laser ophthalmoscopy (CSLO). These testing devices use videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina. Although these techniques are different, their objective is the same. These methods are described below:

Scanning Laser Polarimetry•

The retinal nerve fiber layer (RNFL) is birefringent, causing a change in the state of polarization of a laser beam as it passes. A 780-nm diode laser is used to illuminate the optic nerve. The polarization state of the light emerging from the eye is then evaluated and correlated with RNFL thickness. Unlike confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP) can directly measure the thickness of the RNFL. GDx® is a common example of a scanning laser polarimeter. GDx® contains a normative database and statistical software package to allow comparison to age-matched normal subjects of the same ethnic origin. The advantages of this system are that images can be obtained without pupil dilation, and evaluation can be done in about 10 minutes. Current instruments have added enhanced and variable corneal compensation technology to account for corneal polarization.

Optical Coherence Tomography•

Optical coherence tomography (OCT) uses near-infrared light to provide direct cross-sectional measurement of the retinal nerve fiber layer. The principals employed are similar to those used in B-mode ultrasound except light, not sound, is used to produce the 3-dimensional images. The light source can be directed into the eye

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through a conventional slit-lamp biomicroscope and focused onto the retina through a typical 78-diopter lens. This system requires dilation of the patient’s pupil.

Confocal Scanning Laser Ophthalmoscopy•

Confocal scanning laser ophthalmoscopy (CSLO) is a laser-based image acquisition technique, which is intended to improve the quality of the examination compared to standard ophthalmologic examination. A laser is scanned across the retina along with a detector system. Only a single spot on the retina is illuminated at any time, resulting in a high-contrast image of great reproducibility that can be used to estimate the thickness of the RNFL. In addition, this technique does not require maximal mydriasis, which may be a problem in patients with glaucoma. The Heidelberg Retinal Tomograph is probably the most common example of this technology.

Covered Indications

Anterior segment SCODI will be considered medically reasonable and necessary for evaluation of specified forms of glaucoma and certain disorders of the cornea, iris and ciliary body.

Posterior segment SCODI will be considered medically reasonable and necessary under the following circumstances:

For diagnosis and management of a patient who has mild, moderate, severe or indeterminate stage glaucoma or who is suspected of having glaucoma.

1.

Monitoring patients being treated with chloroquine (CQ) and/or hydroxychloroquine (HCQ) for the development of retinopathy.

2.

The evaluation and treatment of patients with conditions affecting the optic nerve (e.g. optic neuropathy) or retinal disease (e.g., macular degeneration, diabetic retinopathy) and in the evaluation and treatment of certain macular abnormalities (e.g. macular edema, atrophy associated with degenerative retinal diseases).

3.

Limitations

The following are considered not reasonable and necessary and therefore will be denied:

SCODI is usually not medically reasonable and necessary when performed to provide additional confirmatory information regarding a diagnosis which has already been determined. Documentation should support that the SCODI test result was used for establishing a diagnosis, establishing a baseline prior to treatment, or for monitoring purposes.

1.

Fundus photography and posterior segment SCODI performed on the same eye on the same day are generally mutually exclusive of one another (National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services). The provider is not precluded from performing both on the same eye on the same day when each service is necessary to evaluate and treat the patient. The medical record should clearly document the medical necessity of each service. Frequent reporting of these services together may trigger focused medical review.

First Coast’s Fundus Photography LCD (L33670) includes a list of ICD-10 diagnosis codes that would support when fundus photography and posterior segment SCODI are performed on the same eye on the same day.

2.

Screening (patient without signs or symptoms) for any condition is not medically reasonable and necessary.3.

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For frequency limitations please refer to the "Utilization Guidelines" section of the LCD below.

Notice: This LCD imposes frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM Publication 100-08, Chapter 13, Section 13.5.4, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862 (a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

Safe and effective.•

Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).

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Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

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Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

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Furnished in a setting appropriate to the patient's medical needs and condition.•

Ordered and furnished by qualified personnel.•

One that meets, but does not exceed, the patient's medical needs.•

At least as beneficial as an existing and available medically appropriate alternative.•

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Summary of Evidence

Scanning computerized ophthalmic diagnostic imaging (SCODI) allows for the early detection of glaucomatous damage to the nerve fiber layer or optic nerve and has demonstrated clinical utility in facilitating earlier diagnosis and treatment as well as monitoring for progression and response to treatment. Evidence-based guidelines [2015 Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) on Primary Open-Angle Glaucoma and 2010 American Optometric Association (AOA) Optometric Clinical Practice Guideline on Care of the Patient with Open Angle Glaucoma] identify SCODI as one technique that may be used to examine the optic nerve head (ONH) and/or retinal nerve fiber layer (RNFL). SCODI is often used to provide quantitative information to supplement the clinical exam of the optic nerve. SCODI is widely used in the posterior segment, whereas in the anterior segment, the use is still limited.

The evidence-based guideline from the AAO (2015 AAO PPP on Primary Angle Closure) indicates that anterior segment imaging should be considered when angle anatomy is difficult to assess on gonioscopy. There is good

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evidence demonstrating general agreement between findings on gonioscopy and anterior segment imaging, including ultrasound biomicroscopy and anterior segment optical coherence tomography (AS-OCT). However, AS-OCT is limited to evaluating the iridocorneal angle. AS-OCT is one technology that may prove useful in evaluating secondary causes of angle closure and elucidating plateau iris.

SCODI is also a valuable tool for the evaluation of patients with retinal disease, especially those with macular abnormalities. SCODI is often used in conjunction with clinical examination of the eye. It is at times used as a baseline and also used in monitoring for progression or response to treatment. The clinical utility of OCT imaging in retinal conditions has been demonstrated as providing an objective, accurate assessment of the amount and location of retinal thickening. Evidence-based guidelines from the AAO [PPP Diabetic Retinopathy (2016) and the PPP Idiopathic Macular Hole (2014, updated 2017)] support that in clinical practice, decisions are often based on OCT findings.

Finally, Marmor et al. (AAO Statement 2016) published recommendations on screening patients who are being treated with Chloroquine and Hydroxychloroquine. A baseline test is performed and then ongoing monitoring at regular intervals is recommended. Marmor et al. recommends beginning annual screening after 5 years for patients on acceptable doses of chloroquine or hydroxychloroquine and without any major risk factors.

Multiple sources of literature were submitted for consideration of posterior SCODI for advanced (severe) stage glaucoma and anterior SCODI to examine the structures of the anterior segment of the eye.

In an observational case study, Leite et al. (2010) looked at 99 patients with glaucomatous eyes and 47 control patients. The severity of disease was graded using the visual field index (VFI) from standard automated perimetry. The authors looked to determine if disease severity had any impact on the diagnostic accuracy of OCT. The average VFI for the glaucomatous eyes was 85.5% and for the control eyes was 99.4% indicating very minimal visual field loss. The results show that for those with mild disease (VFI near 100%) the sensitivity of OCT was 47% and the specificity was 95%. For those patients with a VFI of 70%, the sensitivity increased to 84% and the specificity was 95%.

Bowd et al. (2017) published a study that looked to estimate the measurement floors for spectral-domain optical coherence tomography (SD-OCT) measurements [minimum rim width (MRW), ganglion cell-inner plexiform layer thickness (GC-IPLT), and circumpapillary retinal nerve fiber layer thickness (cpRNFLT)] and compared global change over time in advanced glaucoma eyes. The study included a variability group of 41 eyes of 27 glaucoma patients with moderate to advanced glaucoma to estimate the measurement floors and 87 eyes of 59 patients with advanced to severe glaucoma in a longitudinal group. Average structural loss of MRW, macular GC-IPLT and cpRNFL thickness in the variability group eyes (over 5 weeks of follow- up) and the longitudinal group eyes (over 2 years of follow-up) was presented. The results indicated the mean percentage of image area that did not reach the floor in the baseline images of eyes in the longitudinal group (i.e., the image percentage that changed after 2 years of follow-up) was 19% for MRW, 36% for GC-IPLT and 14% for cpRNFL thickness, indicating that GC-IPLT likely is the most robust measurement for assessing localized change in eyes with advanced glaucoma eyes. Authors concluded that a significant percentage of SD-OCT-measured retinal tissue is spared from the measurement floor in advanced glaucoma eyes. In addition, progressive thinning of the spared tissue is observable well into late-stage disease, particularly when GC-IPLT is the structural parameter measured. These results indicate that optical imaging, particularly SD-OCT imaging, has a place in detecting structural change in eyes with advanced glaucoma.

Belghith et al. (2016) did a study is to compare SD-OCT standard structural measures MRW, ganglion cell-inner plexiform layer (GC-IPL), and cpRNF and a new three-dimensional (3D) volume optic nerve head (ONH) change detection method for detecting change over time in severely advanced-glaucoma (open-angle glaucoma [OAG]) patients. The study included three groups of participants. The first group was composed of 35 eyes of 35 advanced-

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glaucoma patients followed for an average of 3.5 years. The stable glaucoma group consisted of 50 eyes from 27 early-, moderate-, and advanced-glaucoma patients with five serial OCT exams imaged every week for 5 weeks. A third group of 46 eyes from 30 healthy subjects followed for an average of 2.8 years was used to estimate the aging effects. Results suggest that even in very advanced glaucoma, structural loss can be detected in some eyes using standard global structural measures. Specifically, macular GC-IPL had the highest proportion of eyes with detectable change (31%), followed by MRW (11%) and cpRNFL (4%). In addition, the 3D whole-volume Bayesian-kernel detection scheme (BKDS) change method, which does not require extensive retinal layer segmentation, detected change in 37% of eyes. The authors concluded the results suggest that even in very advanced disease, structural change can be detected, and that monitoring macular GC-IPL and 3D whole-volume patients BKDS change shows promise for identifying progression in advanced glaucoma. However, a larger sample of advanced-glaucoma patients with longer follow-up is needed to validate these findings.

In a retrospective case note review, Hau et al. (2015) compared AS-OCT with ultrasound B-scan (USB) in evaluating iris and iridociliary body lesions. Patients with other anterior or posterior segment lesions or tumors were excluded from this study. The study included 126 patients (126 eyes), the mean age of the patient group was 57.8, who were imaged with both AS-OCT and USB presenting to the same ocular oncology center over a 2 year period of time. The three most common diagnoses were iris naevi, iris pigment epithelial cysts, and iris melanoma. The aim of the study was to evaluate which imaging modality (AS-OCT vs. USB) provided better visualization and characterization of a large cohort of iris and iridociliary body lesions. High-frequency ultrasound biomicroscopy (UBM) was not included in this study, but was referenced as having some distinct advantages over USB and AS-OCT as well as limitations on use. The results revealed that USB was better than AS-OCT in visualizing all tumor margins, posterior tumor margin, and producing less posterior shadowing. USB was slightly better for resolving the overall tumor and posterior tumor surface, but AS-OCT was better for resolving the anterior and lateral tumor surface. In total, AS-OCT was able to detect more lesions than USB, especially in imaging iris lesions, but it was unable to detect any of the ciliary body lesions. The authors concluded that AS-OCT is superior to USB for imaging small lesions pertaining to the anterior iris but USB is better for imaging larger iris lesions with posterior or ciliary body extension.

Janssens et al. (2016) conducted a systematic review to determine how AS-OC and UBM are in determining tumor margins and tumor depth of conjunctival and corneal tumors and if either of these techniques can provide additional information regarding the diagnosis. Fourteen sources were selected to analyze corneal and conjunctival tumor thickness and internal characteristics and extension in depth and size and shape measured by either of these two noninvasive techniques, AS-OCT or UBM, or a combination of both. The study designs included retrospective analysis, retrospective interventional case series, retrospective noninterventional case series, prospective studies, and unknown study designs. The number of patients in articles using UBM (alone) in conjunctival and corneal tumors totaled 44, the number of patients in articles using AS-OCT (alone) in conjunctival and corneal tumors totaled 211 (212 eyes), and the number of patients in articles using both UBM and AS-OCT in conjunctival and corneal tumors totaled 235 (238 tumors). The results show that both AS-OCT and UBM imaging techniques provide useful information about the internal features, extension, size, and shape of tumors. There is not enough evidence on the advantages and disadvantages of AS-OCT and UBM in certain tumor types. The authors concluded that more comparative studies are needed to investigate which imaging technique is most suitable for a certain tumor type.

Analysis of Evidence (Rationale for Determination)

The clinical utility of SCODI has been established and validated in evidence-based guidelines and literature for early detection of glaucomatous damage to the retinal nerve fiber layer or optic disc, differentiation and diagnosis of other disorders of the optic nerve as well as monitoring for progressive optic neuropathy, monitoring retinal conditions, and drug-related ocular toxicity.

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A number of studies have been published to evaluate the usefulness of posterior OCT for individuals with advanced glaucomatous damage as well as the potential applications of anterior segment OCT (AS-OCT and SD-OCT with anterior segment imaging capabilities) to image and provide measurements of anterior segment structures in a number of clinical situations. Overall, these studies have small sample sizes, relatively limited follow-up, and no documentation of improved health outcomes in the Medicare population. Some of the studies have populations that would not be generalizable to the Medicare population.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

CODE DESCRIPTION

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CODE DESCRIPTION

99999 Not Applicable

CPT/HCPCS Codes

Group 1 Paragraph:

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes:

CODE DESCRIPTION

92132 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

Group 2 Paragraph:

N/A

Group 2 Codes:

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CODE DESCRIPTION

92133 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE

Group 3 Paragraph:

N/A

Group 3 Codes:

CODE DESCRIPTION

92134 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph:

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. Medicare is establishing the following limited coverage for CPT code 92132 – anterior segment:

Group 1 Codes:

ICD-10 CODE DESCRIPTION

C69.01 Malignant neoplasm of right conjunctiva

C69.02 Malignant neoplasm of left conjunctiva

C69.11 Malignant neoplasm of right cornea

C69.12 Malignant neoplasm of left cornea

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

H17.01 Adherent leukoma, right eye

H17.02 Adherent leukoma, left eye

H17.03 Adherent leukoma, bilateral

H17.11 Central corneal opacity, right eye

H17.12 Central corneal opacity, left eye

H17.13 Central corneal opacity, bilateral

H17.811 Minor opacity of cornea, right eye

H17.812 Minor opacity of cornea, left eye

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H17.813 Minor opacity of cornea, bilateral

H17.821 Peripheral opacity of cornea, right eye

H17.822 Peripheral opacity of cornea, left eye

H17.823 Peripheral opacity of cornea, bilateral

H17.89 Other corneal scars and opacities

H18.20 Unspecified corneal edema

H18.211 Corneal edema secondary to contact lens, right eye

H18.212 Corneal edema secondary to contact lens, left eye

H18.213 Corneal edema secondary to contact lens, bilateral

H18.221 Idiopathic corneal edema, right eye

H18.222 Idiopathic corneal edema, left eye

H18.223 Idiopathic corneal edema, bilateral

H18.231 Secondary corneal edema, right eye

H18.232 Secondary corneal edema, left eye

H18.233 Secondary corneal edema, bilateral

H21.221 Degeneration of ciliary body, right eye

H21.222 Degeneration of ciliary body, left eye

H21.223 Degeneration of ciliary body, bilateral

H21.231 Degeneration of iris (pigmentary), right eye

H21.232 Degeneration of iris (pigmentary), left eye

H21.233 Degeneration of iris (pigmentary), bilateral

H21.271 Miotic pupillary cyst, right eye

H21.272 Miotic pupillary cyst, left eye

H21.273 Miotic pupillary cyst, bilateral

H21.301 Idiopathic cysts of iris, ciliary body or anterior chamber, right eye

H21.302 Idiopathic cysts of iris, ciliary body or anterior chamber, left eye

H21.303 Idiopathic cysts of iris, ciliary body or anterior chamber, bilateral

H21.311 Exudative cysts of iris or anterior chamber, right eye

H21.312 Exudative cysts of iris or anterior chamber, left eye

H21.313 Exudative cysts of iris or anterior chamber, bilateral

H21.321 Implantation cysts of iris, ciliary body or anterior chamber, right eye

H21.322 Implantation cysts of iris, ciliary body or anterior chamber, left eye

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H21.323 Implantation cysts of iris, ciliary body or anterior chamber, bilateral

H21.89 Other specified disorders of iris and ciliary body

H40.021 Open angle with borderline findings, high risk, right eye

H40.022 Open angle with borderline findings, high risk, left eye

H40.023 Open angle with borderline findings, high risk, bilateral

H40.031 Anatomical narrow angle, right eye

H40.032 Anatomical narrow angle, left eye

H40.033 Anatomical narrow angle, bilateral

H40.061 Primary angle closure without glaucoma damage, right eye

H40.062 Primary angle closure without glaucoma damage, left eye

H40.063 Primary angle closure without glaucoma damage, bilateral

H40.211 Acute angle-closure glaucoma, right eye

H40.212 Acute angle-closure glaucoma, left eye

H40.213 Acute angle-closure glaucoma, bilateral

H40.2211 Chronic angle-closure glaucoma, right eye, mild stage

H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage

H40.2213 Chronic angle-closure glaucoma, right eye, severe stage

H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage

H40.2221 Chronic angle-closure glaucoma, left eye, mild stage

H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage

H40.2223 Chronic angle-closure glaucoma, left eye, severe stage

H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage

H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage

H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage

H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage

H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage

H40.231 Intermittent angle-closure glaucoma, right eye

H40.232 Intermittent angle-closure glaucoma, left eye

H40.233 Intermittent angle-closure glaucoma, bilateral

H40.241 Residual stage of angle-closure glaucoma, right eye

H40.242 Residual stage of angle-closure glaucoma, left eye

H40.243 Residual stage of angle-closure glaucoma, bilateral

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H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage

H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage

H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage

H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage

H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage

H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage

H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage

H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage

H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage

H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage

H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage

H40.33X4 Glaucoma secondary to eye trauma, bilateral, indeterminate stage

T86.840 Corneal transplant rejection

T86.841 Corneal transplant failure

T86.842 Corneal transplant infection

Group 2 Paragraph:

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT code 92133 – optic nerve:

Group 2 Codes:


H40.011 Open angle with borderline findings, low risk, right eye

H40.012 Open angle with borderline findings, low risk, left eye

H40.013 Open angle with borderline findings, low risk, bilateral

H40.021 Open angle with borderline findings, high risk, right eye

H40.022 Open angle with borderline findings, high risk, left eye

H40.023 Open angle with borderline findings, high risk, bilateral

H40.031 Anatomical narrow angle, right eye

H40.032 Anatomical narrow angle, left eye

H40.033 Anatomical narrow angle, bilateral

H40.041 Steroid responder, right eye

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H40.042 Steroid responder, left eye

H40.043 Steroid responder, bilateral

H40.051 Ocular hypertension, right eye

H40.052 Ocular hypertension, left eye

H40.053 Ocular hypertension, bilateral

H40.061 Primary angle closure without glaucoma damage, right eye

H40.062 Primary angle closure without glaucoma damage, left eye

H40.063 Primary angle closure without glaucoma damage, bilateral

H40.1111 Primary open-angle glaucoma, right eye, mild stage

H40.1112 Primary open-angle glaucoma, right eye, moderate stage

H40.1113 Primary open-angle glaucoma, right eye, severe stage

H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage

H40.1121 Primary open-angle glaucoma, left eye, mild stage

H40.1122 Primary open-angle glaucoma, left eye, moderate stage

H40.1123 Primary open-angle glaucoma, left eye, severe stage

H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage

H40.1131 Primary open-angle glaucoma, bilateral, mild stage

H40.1132 Primary open-angle glaucoma, bilateral, moderate stage

H40.1133 Primary open-angle glaucoma, bilateral, severe stage

H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage

H40.1211 Low-tension glaucoma, right eye, mild stage

H40.1212 Low-tension glaucoma, right eye, moderate stage

H40.1213 Low-tension glaucoma, right eye, severe stage

H40.1214 Low-tension glaucoma, right eye, indeterminate stage

H40.1221 Low-tension glaucoma, left eye, mild stage

H40.1222 Low-tension glaucoma, left eye, moderate stage

H40.1223 Low-tension glaucoma, left eye, severe stage

H40.1224 Low-tension glaucoma, left eye, indeterminate stage

H40.1231 Low-tension glaucoma, bilateral, mild stage

H40.1232 Low-tension glaucoma, bilateral, moderate stage

H40.1233 Low-tension glaucoma, bilateral, severe stage

H40.1234 Low-tension glaucoma, bilateral, indeterminate stage

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H40.1311 Pigmentary glaucoma, right eye, mild stage

H40.1312 Pigmentary glaucoma, right eye, moderate stage

H40.1313 Pigmentary glaucoma, right eye, severe stage

H40.1314 Pigmentary glaucoma, right eye, indeterminate stage

H40.1321 Pigmentary glaucoma, left eye, mild stage

H40.1322 Pigmentary glaucoma, left eye, moderate stage

H40.1323 Pigmentary glaucoma, left eye, severe stage

H40.1324 Pigmentary glaucoma, left eye, indeterminate stage

H40.1331 Pigmentary glaucoma, bilateral, mild stage

H40.1332 Pigmentary glaucoma, bilateral, moderate stage

H40.1333 Pigmentary glaucoma, bilateral, severe stage

H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage

H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage

H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage

H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage

H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage

H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage

H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage

H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage

H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage

H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage

H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage

H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage

H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage

H40.211 Acute angle-closure glaucoma, right eye

H40.212 Acute angle-closure glaucoma, left eye

H40.213 Acute angle-closure glaucoma, bilateral

H40.2211 Chronic angle-closure glaucoma, right eye, mild stage

H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage

H40.2213 Chronic angle-closure glaucoma, right eye, severe stage

H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage

H40.2221 Chronic angle-closure glaucoma, left eye, mild stage

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H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage

H40.2223 Chronic angle-closure glaucoma, left eye, severe stage

H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage

H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage

H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage

H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage

H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage

H40.231 Intermittent angle-closure glaucoma, right eye

H40.232 Intermittent angle-closure glaucoma, left eye

H40.233 Intermittent angle-closure glaucoma, bilateral

H40.241 Residual stage of angle-closure glaucoma, right eye

H40.242 Residual stage of angle-closure glaucoma, left eye

H40.243 Residual stage of angle-closure glaucoma, bilateral

H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage

H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage

H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage

H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage

H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage

H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage

H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage

H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage

H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage

H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage

H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage

H40.33X4 Glaucoma secondary to eye trauma, bilateral, indeterminate stage

H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage

H40.41X2 Glaucoma secondary to eye inflammation, right eye, moderate stage


H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage

H40.41X4 Glaucoma secondary to eye inflammation, right eye, indeterminate stage

H40.42X1 Glaucoma secondary to eye inflammation, left eye, mild stage

H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage

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H40.42X3 Glaucoma secondary to eye inflammation, left eye, severe stage

H40.42X4 Glaucoma secondary to eye inflammation, left eye, indeterminate stage

H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage

H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage

H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage

H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage

H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage

H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage

H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage

H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage

H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage

H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage

H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage

H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage

H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage

H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage

H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage

H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage

H40.61X1 Glaucoma secondary to drugs, right eye, mild stage

H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage

H40.61X3 Glaucoma secondary to drugs, right eye, severe stage

H40.61X4 Glaucoma secondary to drugs, right eye, indeterminate stage

H40.62X1 Glaucoma secondary to drugs, left eye, mild stage

H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage

H40.62X3 Glaucoma secondary to drugs, left eye, severe stage

H40.62X4 Glaucoma secondary to drugs, left eye, indeterminate stage

H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage

H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage

H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage

H40.63X4 Glaucoma secondary to drugs, bilateral, indeterminate stage

H40.811 Glaucoma with increased episcleral venous pressure, right eye

H40.812 Glaucoma with increased episcleral venous pressure, left eye

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H40.813 Glaucoma with increased episcleral venous pressure, bilateral

H40.821 Hypersecretion glaucoma, right eye

H40.822 Hypersecretion glaucoma, left eye

H40.823 Hypersecretion glaucoma, bilateral

H40.831 Aqueous misdirection, right eye

H40.832 Aqueous misdirection, left eye

H40.833 Aqueous misdirection, bilateral

H40.89 Other specified glaucoma

H46.01 Optic papillitis, right eye

H46.02 Optic papillitis, left eye

H46.03 Optic papillitis, bilateral

H46.11 Retrobulbar neuritis, right eye

H46.12 Retrobulbar neuritis, left eye

H46.13 Retrobulbar neuritis, bilateral

H46.8 Other optic neuritis

H47.011 Ischemic optic neuropathy, right eye

H47.012 Ischemic optic neuropathy, left eye

H47.013 Ischemic optic neuropathy, bilateral

H47.031 Optic nerve hypoplasia, right eye

H47.032 Optic nerve hypoplasia, left eye

H47.033 Optic nerve hypoplasia, bilateral

H47.11 Papilledema associated with increased intracranial pressure

H47.12 Papilledema associated with decreased ocular pressure

H47.13 Papilledema associated with retinal disorder

H47.141 Foster-Kennedy syndrome, right eye

H47.142 Foster-Kennedy syndrome, left eye

H47.143 Foster-Kennedy syndrome, bilateral

H47.211 Primary optic atrophy, right eye

H47.212 Primary optic atrophy, left eye

H47.213 Primary optic atrophy, bilateral

H47.231 Glaucomatous optic atrophy, right eye

H47.232 Glaucomatous optic atrophy, left eye

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H47.233 Glaucomatous optic atrophy, bilateral

H47.291 Other optic atrophy, right eye

H47.292 Other optic atrophy, left eye

H47.293 Other optic atrophy, bilateral

H47.321 Drusen of optic disc, right eye

H47.322 Drusen of optic disc, left eye

H47.323 Drusen of optic disc, bilateral

H47.331 Pseudopapilledema of optic disc, right eye

H47.332 Pseudopapilledema of optic disc, left eye

H47.333 Pseudopapilledema of optic disc, bilateral

H47.391 Other disorders of optic disc, right eye

H47.392 Other disorders of optic disc, left eye

H47.393 Other disorders of optic disc, bilateral

H53.15 Visual distortions of shape and size

H53.411 Scotoma involving central area, right eye

H53.412 Scotoma involving central area, left eye

H53.413 Scotoma involving central area, bilateral

H53.421 Scotoma of blind spot area, right eye

H53.422 Scotoma of blind spot area, left eye

H53.423 Scotoma of blind spot area, bilateral

H53.431 Sector or arcuate defects, right eye

H53.432 Sector or arcuate defects, left eye

H53.433 Sector or arcuate defects, bilateral

H53.451 Other localized visual field defect, right eye

H53.452 Other localized visual field defect, left eye

H53.453 Other localized visual field defect, bilateral

H53.481 Generalized contraction of visual field, right eye

H53.482 Generalized contraction of visual field, left eye

H53.483 Generalized contraction of visual field, bilateral

Q15.0 Congenital glaucoma

Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation:

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Group 3 Paragraph:

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for CPT code 92134 – retina:

Group 3 Codes:


A18.53 Tuberculous chorioretinitis

B39.4 Histoplasmosis capsulati, unspecified

C69.21 Malignant neoplasm of right retina

C69.22 Malignant neoplasm of left retina

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

D31.31 Benign neoplasm of right choroid

D31.32 Benign neoplasm of left choroid

E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye

E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye

E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye

E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye

E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

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E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye

E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye

E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye

E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye

E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye

E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye

E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral

E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy E08.3541

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with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye

E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye

E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral

E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye

E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye

E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral

E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye

E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye

E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral

E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

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E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy E09.3531

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with traction retinal detachment not involving the macula, right eye

E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

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E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral


E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

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E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

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E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, E11.3513

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bilateral

E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

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E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

Other specified diabetes mellitus with proliferative diabetic retinopathy with macular E13.3512

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edema, left eye

E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

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E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

G45.3 Amaurosis fugax

H30.011 Focal chorioretinal inflammation, juxtapapillary, right eye

H30.012 Focal chorioretinal inflammation, juxtapapillary, left eye

H30.013 Focal chorioretinal inflammation, juxtapapillary, bilateral

H30.021 Focal chorioretinal inflammation of posterior pole, right eye

H30.022 Focal chorioretinal inflammation of posterior pole, left eye

H30.023 Focal chorioretinal inflammation of posterior pole, bilateral

H30.031 Focal chorioretinal inflammation, peripheral, right eye

H30.032 Focal chorioretinal inflammation, peripheral, left eye

H30.033 Focal chorioretinal inflammation, peripheral, bilateral

H30.041 Focal chorioretinal inflammation, macular or paramacular, right eye

H30.042 Focal chorioretinal inflammation, macular or paramacular, left eye

H30.043 Focal chorioretinal inflammation, macular or paramacular, bilateral

H30.111 Disseminated chorioretinal inflammation of posterior pole, right eye

H30.112 Disseminated chorioretinal inflammation of posterior pole, left eye

H30.113 Disseminated chorioretinal inflammation of posterior pole, bilateral

H30.121 Disseminated chorioretinal inflammation, peripheral right eye

H30.122 Disseminated chorioretinal inflammation, peripheral, left eye

H30.123 Disseminated chorioretinal inflammation, peripheral, bilateral

H30.131 Disseminated chorioretinal inflammation, generalized, right eye

H30.132 Disseminated chorioretinal inflammation, generalized, left eye

H30.133 Disseminated chorioretinal inflammation, generalized, bilateral

H30.141 Acute posterior multifocal placoid pigment epitheliopathy, right eye

H30.142 Acute posterior multifocal placoid pigment epitheliopathy, left eye

H30.143 Acute posterior multifocal placoid pigment epitheliopathy, bilateral

H30.21 Posterior cyclitis, right eye

H30.22 Posterior cyclitis, left eye

H30.23 Posterior cyclitis, bilateral

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H30.811 Harada's disease, right eye

H30.812 Harada's disease, left eye

H30.813 Harada's disease, bilateral

H30.891 Other chorioretinal inflammations, right eye

H30.892 Other chorioretinal inflammations, left eye

H30.893 Other chorioretinal inflammations, bilateral

H31.021 Solar retinopathy, right eye

H31.022 Solar retinopathy, left eye

H31.023 Solar retinopathy, bilateral

H31.101 Choroidal degeneration, unspecified, right eye

H31.102 Choroidal degeneration, unspecified, left eye

H31.103 Choroidal degeneration, unspecified, bilateral

H31.111 Age-related choroidal atrophy, right eye

H31.112 Age-related choroidal atrophy, left eye

H31.113 Age-related choroidal atrophy, bilateral

H31.121 Diffuse secondary atrophy of choroid, right eye

H31.122 Diffuse secondary atrophy of choroid, left eye

H31.123 Diffuse secondary atrophy of choroid, bilateral

H31.411 Hemorrhagic choroidal detachment, right eye

H31.412 Hemorrhagic choroidal detachment, left eye

H31.413 Hemorrhagic choroidal detachment, bilateral

H31.421 Serous choroidal detachment, right eye

H31.422 Serous choroidal detachment, left eye

H31.423 Serous choroidal detachment, bilateral

H32 Chorioretinal disorders in diseases classified elsewhere

H33.011 Retinal detachment with single break, right eye

H33.012 Retinal detachment with single break, left eye

H33.013 Retinal detachment with single break, bilateral

H33.021 Retinal detachment with multiple breaks, right eye

H33.022 Retinal detachment with multiple breaks, left eye

H33.023 Retinal detachment with multiple breaks, bilateral

H33.031 Retinal detachment with giant retinal tear, right eye

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H33.032 Retinal detachment with giant retinal tear, left eye

H33.033 Retinal detachment with giant retinal tear, bilateral

H33.041 Retinal detachment with retinal dialysis, right eye

H33.042 Retinal detachment with retinal dialysis, left eye

H33.043 Retinal detachment with retinal dialysis, bilateral

H33.051 Total retinal detachment, right eye

H33.052 Total retinal detachment, left eye

H33.053 Total retinal detachment, bilateral

H33.111 Cyst of ora serrata, right eye

H33.112 Cyst of ora serrata, left eye

H33.113 Cyst of ora serrata, bilateral

H33.191 Other retinoschisis and retinal cysts, right eye

H33.192 Other retinoschisis and retinal cysts, left eye

H33.193 Other retinoschisis and retinal cysts, bilateral

H33.21 Serous retinal detachment, right eye

H33.22 Serous retinal detachment, left eye

H33.23 Serous retinal detachment, bilateral

H33.311 Horseshoe tear of retina without detachment, right eye

H33.312 Horseshoe tear of retina without detachment, left eye

H33.313 Horseshoe tear of retina without detachment, bilateral

H33.321 Round hole, right eye

H33.322 Round hole, left eye

H33.323 Round hole, bilateral

H33.331 Multiple defects of retina without detachment, right eye

H33.332 Multiple defects of retina without detachment, left eye

H33.333 Multiple defects of retina without detachment, bilateral

H33.41 Traction detachment of retina, right eye

H33.42 Traction detachment of retina, left eye

H33.43 Traction detachment of retina, bilateral

H33.8 Other retinal detachments

H34.01 Transient retinal artery occlusion, right eye

H34.02 Transient retinal artery occlusion, left eye

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H34.03 Transient retinal artery occlusion, bilateral

H34.11 Central retinal artery occlusion, right eye

H34.12 Central retinal artery occlusion, left eye

H34.13 Central retinal artery occlusion, bilateral

H34.211 Partial retinal artery occlusion, right eye

H34.212 Partial retinal artery occlusion, left eye


H34.213 Partial retinal artery occlusion, bilateral

H34.231 Retinal artery branch occlusion, right eye

H34.232 Retinal artery branch occlusion, left eye

H34.233 Retinal artery branch occlusion, bilateral

H34.8110 Central retinal vein occlusion, right eye, with macular edema

H34.8111 Central retinal vein occlusion, right eye, with retinal neovascularization

H34.8112 Central retinal vein occlusion, right eye, stable

H34.8120 Central retinal vein occlusion, left eye, with macular edema

H34.8121 Central retinal vein occlusion, left eye, with retinal neovascularization

H34.8122 Central retinal vein occlusion, left eye, stable

H34.8130 Central retinal vein occlusion, bilateral, with macular edema

H34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularization

H34.8132 Central retinal vein occlusion, bilateral, stable

H34.821 Venous engorgement, right eye

H34.822 Venous engorgement, left eye

H34.823 Venous engorgement, bilateral

H34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edema

H34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization

H34.8312 Tributary (branch) retinal vein occlusion, right eye, stable

H34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edema

H34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularization

H34.8322 Tributary (branch) retinal vein occlusion, left eye, stable

H34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edema

H34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization

H34.8332 Tributary (branch) retinal vein occlusion, bilateral, stable

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H35.011 Changes in retinal vascular appearance, right eye

H35.012 Changes in retinal vascular appearance, left eye

H35.013 Changes in retinal vascular appearance, bilateral

H35.021 Exudative retinopathy, right eye

H35.022 Exudative retinopathy, left eye

H35.023 Exudative retinopathy, bilateral

H35.031 Hypertensive retinopathy, right eye

H35.032 Hypertensive retinopathy, left eye

H35.033 Hypertensive retinopathy, bilateral

H35.041 Retinal micro-aneurysms, unspecified, right eye

H35.042 Retinal micro-aneurysms, unspecified, left eye

H35.043 Retinal micro-aneurysms, unspecified, bilateral

H35.051 Retinal neovascularization, unspecified, right eye

H35.052 Retinal neovascularization, unspecified, left eye

H35.053 Retinal neovascularization, unspecified, bilateral

H35.061 Retinal vasculitis, right eye

H35.062 Retinal vasculitis, left eye

H35.063 Retinal vasculitis, bilateral

H35.071 Retinal telangiectasis, right eye

H35.072 Retinal telangiectasis, left eye

H35.073 Retinal telangiectasis, bilateral

H35.09 Other intraretinal microvascular abnormalities

H35.171 Retrolental fibroplasia, right eye

H35.172 Retrolental fibroplasia, left eye

H35.173 Retrolental fibroplasia, bilateral

H35.21 Other non-diabetic proliferative retinopathy, right eye

H35.22 Other non-diabetic proliferative retinopathy, left eye

H35.23 Other non-diabetic proliferative retinopathy, bilateral

H35.3110 Nonexudative age-related macular degeneration, right eye, stage unspecified

H35.3111 Nonexudative age-related macular degeneration, right eye, early dry stage

H35.3112 Nonexudative age-related macular degeneration, right eye, intermediate dry stage

Nonexudative age-related macular degeneration, right eye, advanced atrophic H35.3113

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without subfoveal involvement

H35.3114 Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement

H35.3120 Nonexudative age-related macular degeneration, left eye, stage unspecified

H35.3121 Nonexudative age-related macular degeneration, left eye, early dry stage

H35.3122 Nonexudative age-related macular degeneration, left eye, intermediate dry stage

H35.3123 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement

H35.3124 Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement

H35.3130 Nonexudative age-related macular degeneration, bilateral, stage unspecified

H35.3131 Nonexudative age-related macular degeneration, bilateral, early dry stage

H35.3132 Nonexudative age-related macular degeneration, bilateral, intermediate dry stage

H35.3133 Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement

H35.3134 Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement

H35.3210 Exudative age-related macular degeneration, right eye, stage unspecified

H35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularization

H35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization

H35.3213 Exudative age-related macular degeneration, right eye, with inactive scar

H35.3220 Exudative age-related macular degeneration, left eye, stage unspecified

H35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization

H35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization

H35.3223 Exudative age-related macular degeneration, left eye, with inactive scar

H35.3230 Exudative age-related macular degeneration, bilateral, stage unspecified

H35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization

H35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization

H35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar

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H35.33 Angioid streaks of macula

H35.341 Macular cyst, hole, or pseudohole, right eye

H35.342 Macular cyst, hole, or pseudohole, left eye

H35.343 Macular cyst, hole, or pseudohole, bilateral

H35.351 Cystoid macular degeneration, right eye

H35.352 Cystoid macular degeneration, left eye

H35.353 Cystoid macular degeneration, bilateral

H35.361 Drusen (degenerative) of macula, right eye

H35.362 Drusen (degenerative) of macula, left eye

H35.363 Drusen (degenerative) of macula, bilateral

H35.371 Puckering of macula, right eye

H35.372 Puckering of macula, left eye

H35.373 Puckering of macula, bilateral

H35.381 Toxic maculopathy, right eye

H35.382 Toxic maculopathy, left eye

H35.383 Toxic maculopathy, bilateral

H35.40 Unspecified peripheral retinal degeneration

H35.411 Lattice degeneration of retina, right eye

H35.412 Lattice degeneration of retina, left eye

H35.413 Lattice degeneration of retina, bilateral


H35.421 Microcystoid degeneration of retina, right eye

H35.422 Microcystoid degeneration of retina, left eye

H35.423 Microcystoid degeneration of retina, bilateral

H35.431 Paving stone degeneration of retina, right eye

H35.432 Paving stone degeneration of retina, left eye

H35.433 Paving stone degeneration of retina, bilateral

H35.441 Age-related reticular degeneration of retina, right eye

H35.442 Age-related reticular degeneration of retina, left eye

H35.443 Age-related reticular degeneration of retina, bilateral

H35.451 Secondary pigmentary degeneration, right eye

H35.452 Secondary pigmentary degeneration, left eye

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H35.453 Secondary pigmentary degeneration, bilateral

H35.461 Secondary vitreoretinal degeneration, right eye

H35.462 Secondary vitreoretinal degeneration, left eye

H35.463 Secondary vitreoretinal degeneration, bilateral

H35.50 Unspecified hereditary retinal dystrophy

H35.51 Vitreoretinal dystrophy

H35.52 Pigmentary retinal dystrophy

H35.53 Other dystrophies primarily involving the sensory retina

H35.54 Dystrophies primarily involving the retinal pigment epithelium

H35.61 Retinal hemorrhage, right eye

H35.62 Retinal hemorrhage, left eye

H35.63 Retinal hemorrhage, bilateral

H35.70 Unspecified separation of retinal layers

H35.711 Central serous chorioretinopathy, right eye

H35.712 Central serous chorioretinopathy, left eye

H35.713 Central serous chorioretinopathy, bilateral

H35.721 Serous detachment of retinal pigment epithelium, right eye

H35.722 Serous detachment of retinal pigment epithelium, left eye

H35.723 Serous detachment of retinal pigment epithelium, bilateral

H35.731 Hemorrhagic detachment of retinal pigment epithelium, right eye

H35.732 Hemorrhagic detachment of retinal pigment epithelium, left eye

H35.733 Hemorrhagic detachment of retinal pigment epithelium, bilateral

H35.81 Retinal edema

H35.82 Retinal ischemia

H35.89 Other specified retinal disorders

H40.831 Aqueous misdirection, right eye

H40.832 Aqueous misdirection, left eye

H40.833 Aqueous misdirection, bilateral

H40.89 Other specified glaucoma

H43.811 Vitreous degeneration, right eye

H43.812 Vitreous degeneration, left eye

H43.813 Vitreous degeneration, bilateral

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H43.821 Vitreomacular adhesion, right eye

H43.822 Vitreomacular adhesion, left eye

H43.823 Vitreomacular adhesion, bilateral

H44.2A1 Degenerative myopia with choroidal neovascularization, right eye

H44.2A2 Degenerative myopia with choroidal neovascularization, left eye

H44.2A3 Degenerative myopia with choroidal neovascularization, bilateral eye

H44.2B1 Degenerative myopia with macular hole, right eye

H44.2B2 Degenerative myopia with macular hole, left eye

H44.2B3 Degenerative myopia with macular hole, bilateral eye

H44.2C1 Degenerative myopia with retinal detachment, right eye

H44.2C2 Degenerative myopia with retinal detachment, left eye

H44.2C3 Degenerative myopia with retinal detachment, bilateral eye

H44.2D1 Degenerative myopia with foveoschisis, right eye

H44.2D2 Degenerative myopia with foveoschisis, left eye

H44.2D3 Degenerative myopia with foveoschisis, bilateral eye

H44.2E1 Degenerative myopia with other maculopathy, right eye

H44.2E2 Degenerative myopia with other maculopathy, left eye

H44.2E3 Degenerative myopia with other maculopathy, bilateral eye

H47.11 Papilledema associated with increased intracranial pressure

H47.12 Papilledema associated with decreased ocular pressure

H47.13 Papilledema associated with retinal disorder

H47.141 Foster-Kennedy syndrome, right eye

H47.142 Foster-Kennedy syndrome, left eye

H47.143 Foster-Kennedy syndrome, bilateral

H53.15 Visual distortions of shape and size

H53.411 Scotoma involving central area, right eye

H53.412 Scotoma involving central area, left eye

H53.413 Scotoma involving central area, bilateral

H53.421 Scotoma of blind spot area, right eye

H53.422 Scotoma of blind spot area, left eye

H53.423 Scotoma of blind spot area, bilateral

H53.431 Sector or arcuate defects, right eye

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H53.432 Sector or arcuate defects, left eye

H53.433 Sector or arcuate defects, bilateral

H53.451 Other localized visual field defect, right eye

H53.452 Other localized visual field defect, left eye

H53.453 Other localized visual field defect, bilateral

H53.481 Generalized contraction of visual field, right eye

H53.482 Generalized contraction of visual field, left eye

H53.483 Generalized contraction of visual field, bilateral

H59.031 Cystoid macular edema following cataract surgery, right eye

H59.032 Cystoid macular edema following cataract surgery, left eye

H59.033 Cystoid macular edema following cataract surgery, bilateral

Z79.899 Other long term (current) drug therapy

Group 3 Medical Necessity ICD-10 Codes Asterisk Explanation:

*Note: Z79.899 is to be reported for the baseline evaluation and for annual monitoring of patients on chloroquine (CQ) and hydroxychloroquine (HCQ).

ICD-10 Codes that DO NOT Support Medical Necessity

Group 1 Paragraph:

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this LCD.

Group 1 Codes: N/A

Additional ICD-10 Information

N/A

General InformationAssociated Information

Documentation Requirements

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

1.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

2.

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The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

3.

The medical record documentation must support the medical necessity of the services as directed in this LCD.4. Medical record must include the test results, comparison with prior tests when applicable, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams.

5.

If applicable, medical record documentation must clearly indicate the rationale which supports the medical necessity for performing the fundus photography and posterior segment SCODI on the same day on the same eye. Documentation should also reflect how the test results were used in the patient’s plan of care.

6.

If bilateral studies are performed, the documentation maintained by the provider must demonstrate medical need for the performance of the test for each eye.

7.

When reporting ICD-10-CM code Z79.899, the medical record must reflect the medication administered as well as the underlying condition for which it was given.

8.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

CPT code 92132

No more than (2) exams per year will be considered medically reasonable and necessary for covered indications.

•

CPT code 92133

No more than two (2) exams per year will be considered medically reasonable and necessary for the patient who has or is suspected of having glaucoma.

•

CPT code 92134

No more than one (1) exam every two (2) months will be considered medically reasonable and necessary to manage the patient whose primary ophthalmological condition is related to a retinal disease that is not undergoing active treatment.*

•

*Note: Please see next bullet if undergoing active treatment.

No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment. These conditions include wet AMD, choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema. With the development of treat and extend protocols for patients with wet AMD treated with antiangiogenic drugs, it is expected that SCODI (unilateral or bilateral) will be used for therapeutic decision making and utilized at a maximum of monthly with subsequent less frequency based on the patient treatment protocol and patient response as documented in the medical record.

In addition, other conditions which may undergo rapid clinical changes monthly requiring aggressive therapy and frequent follow-up (e.g. macular hole and traction retinal detachment) may also require monthly scans.

•

No more than one (1) exam per year will be considered medically reasonable and necessary for patients being •

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treated with CQ and/or HCQ. These patients should receive a baseline examination within the first year of treatment and as an annual follow-up after five years of treatment. For higher-risk patients, annual testing may begin immediately (without a 5-year delay).

Sources of Information

Contractor is not responsible for the continued viability of websites listed.

Bibliography

Aetna Clinical Policy Bulletin Number 0749. Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging. Effective 03/21/2008, Last review 10/13/2016. Last Accessed 05/01/2017 at http://www.aetna.com/cpb/medical/data/700_799/0749.html

American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. Preferred Practice Pattern. San Francisco, CA: AAO; 2016. Last Accessed 05/01/2017 at https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2016

American Academy of Ophthalmology (AAO), Glaucoma Panel. Primary Angle Closure. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. Last Accessed 05/01/2017 https://www.aao.org/preferred-practice-pattern/primary-angle-closure-ppp-2015

American Academy of Ophthalmology (AAO), Glaucoma Panel. Primary Open-Angle Glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. Last Accessed 05/01/2017 http://www.aaojournal.org/article/S0161-6420(15)01276-2/pdf.

American Academy of Ophthalmology (AAO), Glaucoma Panel. Primary Open-Angle Glaucoma Suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. Last Accessed 05/01/2017 http://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf.

American Academy of Ophthalmology (AAO), Retina/Vitreous Panel. Diabetic Retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; Updated 2016. Last Accessed 05/01/2017 https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016

American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole. San Francisco, CA: American Academy of Ophthalmology; 2014 (Updated 2017). Available at: www.aao.org/ppp.

American Academy of Ophthalmology. Web Extra: CPT code 92133 (SCODI).EyeNet Magazine. June 2015. Accessed at https://www.aao.org/eyenet

American Glaucoma Society and American Academy of Ophthalmology. Glaucoma Stage Definitions. Glaucoma Quick Reference Guide. Revised 02/17/2015.

American Optometric Association (AOA), Optometric Clinical Practice Guideline. Care of the Patient with Open Angle Glaucoma. St. Louis, MO: revised 2010.

American Optometric Association (AOA), Optometric Clinical Practice Guideline. Care of the Patient with Primary

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https://www.aao.org/eyenet

Angle Closure Glaucoma. St. Louis, MO: revised 1998.

Angmo D, Nongpiur ME, Sharma R, et al. Clinical utility of anterior segment swept-source optical coherence tomography in glaucoma. Oman J Ophthalmol. 2016 Jan-Apr;9(1):3-10.

Bakri SJ, Berrocal A, Capone A, et al. Posterior Vitreous Detachment. Retinal Health Series – Facts from the ASRS. The Foundation American Society of Retina Specialists. 2016. savingvision.org.

Belghith A, Medeiros FA, Bowd C, et al. Structural Change Can Be Detected in Advanced-Glaucoma Eyes. Invest Ophthalmol Vis Sci.2016 Jul 1;57(9):OCT511-8.

Bowd C, Zangwill LM, Weinreb RN, et al. Estimating Optical Coherence Tomography Structural Measurement Floors to Improve Detection of Progression in Advanced Glaucoma. Am J Ophthalmol. 2017 Mar;175:37-44.

Chen Y, Qian Y, Lu P. Iridoschisis: a case report and literature review. BMC Ophthalmol. 2017 Mar 14;17(1):24.

de Moraes CG, Liebmann JM, Medeiros FA, et al. Management of advanced glaucoma: Characterization and monitoring. Surv Ophthalmol. 2016 Sep-Oct;61(5):597-615.

Dolan, B. Optical Coherence Tomography of Ocular Diseases, 2nd ed. Book review. 2005; 82(12):1010

Ehlers, J. et. al. The Prospective Intraoperative and Perioperative Ophthalmic ImagiNg with Optical CoherEncE TomogRaphy (PIONEER) Study: 2-year Results Am J Ophthalmol. 2014; 158(5): 999–1007.

Fernandez-Vigo JI, Fernandez-Vigo C, Martinez de la Casa JM, et al. Identification of iridocorneal angle structures assessed by Fourier domain optical coherence tomography. Arch Soc Esp Oftalmol. 2016 Feb;91(2):74-80.

Florida Blue Medical Coverage Guideline 01-92000-17 Scanning Computerized Ophthalmic Diagnostic Imaging; effective 04/17/2000; revised 10/01/2016.

Han SB, Liu YC, Noriega KM, et al. Applications of Anterior Segment Optical Coherence Tomography in Cornea and Ocular Surface Diseases. J Ophthalmol. 2016;2016:4971572.

Hau SC, Papastefanou V, Shah S, et al. Evaluation of iris and iridociliary body lesions with anterior segment optical coherence tomography versus ultrasound B-scan. Br J Ophthalmol. 2015 Jan;99(1):81-6.

Janssens K, Martens M, Lauwers N, et al. To Study and Determine the Role of Anterior Segment Optical Coherence Tomography and Ultrasound Biomicroscopy in Corneal and Conjunctival Tumors. J Ophthalmol. 2016;2016:1048760. doi: 10.1155/2016/1048760. Epub 2016 Dec 6.

Kim KE, Oh S, Jeoung JW, et al. Spectral-domain Optical Coherence Tomography in Manifest Glaucoma: Its Additive Role in Structural Diagnosis. Am J Ophthalmol. 2016 Nov;171:18-26.

Kreda SH. Diagnosis and Management of Optic Disc Elevation. Optometric Management. 2009. Accessed at http://www.optometricmanagement.com/issues/2009/june-2009/diagnosis-and-management-of-optic-disc-elevation

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Leite MT, Zangwill LM, Weinreb RN, et al. Effect of Disease Severity on the Performance of Cirrus Spectral-Domain OCT for Glaucoma Diagnosis. Invest Ophthalmol Vis Sci. 2010 Aug;51(8):4104-4109.

Marmor MF, Kellner U, Lai TY, et al. American Academy of Ophthalmology. Recommendations on screening for Chloroquine and Hydroxychloroquine retinopathy (2016 Revision). Ophthalmology. 2016 Jun;123(6):1386-1394.

National Institutes of Health (NIH), National Eye Institute (NEI). Retinal Disease Program – National Plan for Eye and Vision Research [NEI Strategic Planning]. Accessed at https://nei.nih.gov/strategicplanning/np_retinal

Nongpiur, ME, Aboobakar IF, Baskaran M, et al. Association of Baseline Anterior Segment Parameters With the Development of Incident Gonioscopic Angle Closure. JAMA Ophthalmol.2017 Mar 1;135(3)252-258.

Rao HL, Yadav RK, Addepalli UK, et al. Comparing spectral-domain optical coherence tomography and standard automated perimetry to diagnose glaucomatous optic neuropathy. J Glaucoma. 2015 Jun-Jul;24(5):e69-74.

Suda K, Hangai M, Akagi T, et al. Comparison of Longitudinal Changes in Functional and Structural Measures for Evaluating Progression of Glaucomatous Optic Neuropathy. Invest Ophthalmol Vis Sci. 2015 Aug;56(9):5477-84.

Thomas BJ, Galor A, Nanji AA, et al. Ultra high-resolution anterior segment optical coherence tomography in the diagnosis and management of ocular surface squamous neoplasia. Ocul Surf. 2014 Kam;12(1):46-58.

Tun TA, Baskaran M, Tan SS, et al. Evaluation of the Anterior Segment Angle-to-Angle Scan of Cirrus High-Definition Optical Coherence Tomography and Comparison With Gonioscopy and With the Visante OCT. Invest Ophthalmol Vis Sci. 2017 Jan;58(1):59-64.

Windsor, M. et.al. Estimating Public and Patient Savings From Basic Research—A Study of Optical Coherence Tomography in Managing Antiangiogenic Therapy. Am J Ophthalmol, 2018; 185:115–122.

Wykoff, C. et.al. Prospective Trial of Treat-and-Extend versus Monthly Dosing for Neovascular Age-Related Macular Degeneration. Ophthalmology. 2015; 122(12):2514-22

Xu BY, Israelsen P, Pan BX, et al. Benefit of Measuring Anterior Segment Structures Using an Increased Number of Optical Coherence Tomography Images: The Chinese American Eye Study. Invest Ophthalmol Vis Sci. 2016 Nov; 57(14):6313-6319

Other Contractor's LCDs

National Government Services, Inc. Local Coverage Determination (LCD) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34380).

Novitas Solutions, Inc. Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (L35038)

Contractor Medical Directors

First Coast Service Options, Inc. Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic

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https://nei.nih.gov/strategicplanning/np_retinal

Imaging (L33751) with effective dates prior to 01/25/2018.

Revision History InformationREVISION HISTORY DATE

REVISION HISTORY NUMBER

REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE

01/29/2019 R15Revision Number: 12 Publication: February 2019 Connection LCR A/B2019-017

Explanation of Revision: Based on review of the LCD, grammatical errors were corrected. The effective date of this revision is based on process date. Also, based on CR 10901, the “Coverage Indications, Limitations, and/or Medical Necessity” section of the LCD was revised to update the section number for Pub. 100-08, Chapter 13 from 13.5.1 to 13.5.4. In addition, “Pub. 100-08, Chapter 13, Section 13.5.4” was added to the “CMS National Coverage Policy” section of the LCD. The effective date of this revision is for claims processed on or after 01/08/2019, for dates of service on or after 09/26/2018.

Other (Revisions based on review.)

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05/31/2018 R14Revision Number: 11 Publication: June 2018 Connection LCR A/B2018-051

Explanation of Revision: The “Bibliography” section of the LCD was updated to include multiple published sources from a reconsideration request. The content of the LCD has not been changed in response to the reconsideration request. The effective date of this revision is based on date of service.

Reconsideration Request

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Revision Number: 10

Publication: December 2017 Connection

LCR A/B2017-045

Explanation of Revision: The local coverage determination (LCD) was revised to update the following sections: “Coverage Indications, Limitations, and/or Medical Necessity,” “History/Background and/or General Information,” “Covered Indications,” “Limitations,” “CPT/HCPCS Codes,” ICD-10 Codes that Support Medical Necessity,” “Documentation

01/25/2018 R13Creation of Uniform LCDs With Other MAC Jurisdiction

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REVISION HISTORY DATE



Requirements,” and “Utilization Guidelines.” Language in these sections was revised to address the reasonable & necessary requirements for SCODI procedures. A background/history for these procedures was added to the LCD. The indications and limitations of coverage were revised to include SCODI services that will and will not be considered medically reasonable and necessary. Diagnosis codes were revised due to inappropriate codes in the LCD following ICD-10-CM transition. Additional requirements were added to the “Documentation Requirements” section of the LCD. Utilization parameters were added for patients whose primary ophthalmological condition is related to a retinal disease and patients with retinal conditions undergoing active intravitreal drug treatment. In addition, the “Sources of Information and Basis for Decision” section of the LCD has been updated. The effective date of this revision is based on date of service.

10/01/2017 R12Revision Number: 11

Publication: September 2017 Connection

LCR A/B2017-038

Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Added ICD-10-CM diagnosis code H44.2A1 – H44.2E9 for procedure codes 92133, 92134. The effective date of this revision is based on date of service.

10/01/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

Revisions Due To ICD-10-CM Code Changes

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Revision Number: 10 Publication: N/A LCR A/B 2017-007 Explanation of Revision: The “CPT/HCPCS Codes” section of the LCD was revised to remove CPT code 92132 from the “Group 1 Codes:” and create a “Group 2 Codes:” to include

02/14/2017 R11Other•

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CPT code 92132 to align with how the diagnosis groups are set up under the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is based on process date

10/01/2016 R10 Revision Number: 9 Publication: October 2016 Connection LCR A/B2016-097 Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Deleted diagnosis codes E08.359, E09.359, E10.359, E11.359, and E13.359 and revised diagnosis code ranges as follows: E08.311-E08.359 to read E08.311-E08.3599, E09.311-E09.359 to read E09.311-E09.3599, E10.311-E10.359 to read E10.311-E10.3599, E11.311-E11.359 to read E11.311-E11.3599, and E13.311-E13.359 to read E13.311-E13.3599. Added new ICD-10-CM diagnosis code ranges E08.37X1-E08.37X9, E09.37X1-E09.37X9, E10.37X1-E10.37X9, E11.37X1-E11.37X9, and E13.37X1-E13.37X9. Changed diagnosis code ranges H34.811-H34.819 to H34.8110-H34.8192 and H34.831H34.839 to H34.8310-H34.8392 in "Group 1 codes that support medical necessity", section of the LCD and H34.811–H34.839 to H34.8110-H34.8392 in the "Limitations of Coverage for Posterior Segment SCODI" section of the LCD. Added ICD-10-CM code Z79.84 for CPT code 92134. The effective date of this revision is based on date of service.


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07/22/2016 R9 Revision Number: 8 Publication: July 2016 Connection LCR A/B 2016-084 Explanation of revision: This LCD was revised to include ICD-10 diagnosis code Z03.89 in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT code 92134. The effective date of this revision is for claims processed on or after 07/22/2016, for dates of service on or after 10/01/15.


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Revision Number: 7 Publication: February 2016 Connection LCR A/B 2016-041 Explanation of revision: This LCD was revised to include ICD-10 diagnosis codes H40.032 and H40.033 in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for

02/18/2016 R8Other•Revisions Due To ICD-10-CM Code Changes

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CPT codes 92132. The effective date of this revision is for claims processed on or after 02/18/2016, for dates of service on or after 10/01/15. In addition, the LCD was revised to add language to the “Indications of Coverage for Posterior Segment SCODI” section of the LCD to clarify retinal disease coverage. The effective date of this revision is based on claims processed on or after 02/18/16.

02/18/2016 R7 Revision Number: 7 Publication: February 2016 Connection LCR A/B 2016-041 Explanation of revision: This LCD was revised to include ICD-10 diagnosis codes H40.032 and H40.033 in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT codes 92132. The effective date of this revision is for claims processed on or after 02/18/2016, for dates of service on or after 10/01/15.


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10/01/2015 R6 Revision Number: 6 Publication: November 2015 Connection LCR A/B 2015-031 Explanation of revision: This LCD was revised to include ICD-10 code range H59.031–H59.039 in the “Indications and Limitations of Coverage and/or Medical Necessity” and “ICD-10 Codes that Support Medical Necessity” sections of the LCD for CPT codes 92133 and 92134. The effective date of this revision is for claims processed on or after 11/19/2015, for dates of service on or after 10/01/15.


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10/01/2015 R5 Revision Number: 5 Publication: November 2015 Connection LCR A/B2015 Explanation of revision: LCD revised to add additional ICD-10-CM diagnosis codes H43.00-H43.9 to the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is for claims processed on or after 10/29/15, for dates of service on or after 10/01/15.


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Other (Added ICD-10 code range; H43.00— H43.9)

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Revisions Due To •

10/01/2015 R4 10/28/2015-Added ICD-10 code range; H43.00— H43.9 Vitreous prolapse, unspecified eye— Unspecified disorder of vitreous body.

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ICD-10-CM Code Changes

10/01/2015 R3 5/29/2015-The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.

Provider Education/Guidance

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10/01/2015 R2 04/22/15- - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.


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10/01/2015 R1 06/05/2014 – The language and/or ICD-10-CM diagnoses were updated to be consistent with current LCD language and ICD-9-CM coding.


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New/Updated Technology

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Associated DocumentsAttachments

N/A

Related Local Coverage Documents

Article(s) A55824 - Response to Comments: L33751 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56304 - Scanning computerized ophthalmic diagnostic imaging (SCODI) revision to the Part A and Part B LCD

Related National Coverage Documents

N/A

Public Version(s)

Updated on 02/01/2019 with effective dates 01/29/2019 - N/A Updated on 06/20/2018 with effective dates 05/31/2018 - 01/28/2019 Updated on 11/30/2017 with effective dates 01/25/2018 - 05/30/2018 Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

KeywordsN/A

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