Local Coverage Determination (LCD): Visual Field Examination (L33766)

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Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s) First Coast Service Options, Inc. A and B MAC 09101 - MAC A J - N Florida First Coast Service Options, Inc. A and B MAC 09102 - MAC B J - N Florida Puerto Rico First Coast Service Options, Inc. A and B MAC 09201 - MAC A J - N Virgin Islands First Coast Service Options, Inc. A and B MAC 09202 - MAC B J - N Puerto Rico First Coast Service Options, Inc. A and B MAC 09302 - MAC B J - N Virgin Islands Back to Top LCD Information

Document Information

LCD ID Original Effective Date L33766 For services performed on or after 10/01/2015

Original ICD-9 LCD ID Revision Effective Date L29006 For services performed on or after 10/01/2015

LCD Title Revision Ending Date Visual Field Examination N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement Retirement Date CPT only copyright 2002-2015 American Medical N/A Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Notice Period Start Date Applicable FARS/DFARS Apply to Government Use. Fee N/A schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not Notice Period End Date recommending their use. The AMA does not directly or N/A indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.

Printed on 4/26/2016. Page 1 of 9 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

CMS National Coverage Policy Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

N/A

Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

The visual field is the area within which objects may be seen when the is fixed. To standardize testing, several automated and computerized perimeters are available. However, manual perimeters are also utilized.

Visual field examinations will be considered medically reasonable and necessary under any of the following conditions:

· The patient has inflammation or disorders of the potentially affecting the visual field.

· The patient has a documented diagnosis of .

Please note: stabilization or progression of glaucoma can be monitored only by a visual field examination, and the frequency of such examinations is dependent on the variability of intraocular pressure measurements (e.g., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the .

· The patient is a glaucoma suspect as evidenced by an increase in intraocular pressure, asymmetric intraocular measurements of greater than 2-3 mm Hg between the two , or has optic nerves suspicious for glaucoma which may be manifested as asymmetrical cupping, disc hemorrhage, or an absent or thinned temporal rim.

· The patient has a documented disorder of the optic nerve, the neurologic visual pathway, or .

Please note: patients with a previously diagnosed do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed do not need a follow-up visual field unless other presenting symptomatology is documented. In patients about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field is not indicated.

· The patient has had a recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.

· The patient has a recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia, or giant cell arteritis.

· The patient is having an initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital .

· The patient has inflammation or disorders of the , potentially affecting the visual field.

· The patient has sustained a significant eye injury.

· The patient has an unexplained visual loss which may be described as “trouble seeing” or “vision going in and out”.

Printed on 4/26/2016. Page 2 of 9 · The patient has a pale or swollen optic nerve documented by a visual exam of recent origin.

· The patient is having some new functional limitations which may be due to visual field loss (e.g., reports by family that patient is running into things).

· The patient is being evaluated initially for or has experienced central vision loss resulting in vision measured at or below 20/70.

Please note: repeated examinations for a diagnosis of macular degeneration or an experienced central vision loss are not necessary unless changes in vision are documented or to evaluate the results of a surgical intervention.

· The patient is receiving or has completed treatment of a high-risk medication that may cause visual side effects (e.g., a patient on plaquenil may develop ).

Back to Top 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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 085x Critical Access Hospital

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.

051X Clinic - General Classification 0920 Other Diagnostic Services - General Classification

CPT/HCPCS Codes Group 1 Paragraph: N/A

Group 1 Codes: VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; 92081 LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT) VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR 92082 SEMIQUANTITATIVE, AUTOMATED SUPRATHRESHOLD SCREENING PROGRAM, HUMPHREY SUPRATHRESHOLD AUTOMATIC DIAGNOSTIC TEST, OCTOPUS PROGRAM 33) VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND 92083 STATIC DETERMINATION WITHIN THE CENTRAL 30 DEG;, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G-1, 32 OR 42, HUMPHREY VISUAL FIELD ANALYZER FULL THRESHOLD PROGRAMS 30-2, 24-2, OR 30/60-2)

Printed on 4/26/2016. Page 3 of 9 ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: N/A

Group 1 Codes: ICD-10 Codes Description A18.52 - Tuberculous - Other tuberculosis of eye A18.59 A52.12 Other cerebrospinal syphilis A52.14 - Late syphilitic encephalitis - Late syphilitic neuropathy A52.15 A52.19 Other symptomatic A52.73 Symptomatic late syphilis of other respiratory organs A52.76 Other genitourinary symptomatic late syphilis A52.79 Other symptomatic late syphilis B60.13 due to Acanthamoeba C69.00 - Malignant neoplasm of unspecified - Malignant neoplasm of unspecified site of left C69.92 eye C70.0 Malignant neoplasm of cerebral meninges C70.9 Malignant neoplasm of meninges, unspecified Malignant neoplasm of cerebrum, except lobes and ventricles - Malignant neoplasm of brain, C71.0 - C71.9 unspecified C72.20 - Malignant neoplasm of unspecified olfactory nerve - Malignant neoplasm of other cranial nerves C72.59 C79.32 - Secondary malignant neoplasm of cerebral meninges - Secondary malignant neoplasm of other C79.49 parts of nervous system D09.20 - Carcinoma in situ of unspecified eye - Carcinoma in situ of left eye D09.22 D31.00 - Benign neoplasm of unspecified conjunctiva - Benign neoplasm of unspecified part of left eye D31.92 D33.3 Benign neoplasm of cranial nerves D35.2 - D35.3 Benign neoplasm of pituitary gland - Benign neoplasm of craniopharyngeal duct Neoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal D44.3 - D44.5 gland Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system - D49.7 - D49.89 Neoplasm of unspecified behavior of other specified sites D57.00 - Hb-SS disease with crisis, unspecified - Sickle-cell/Hb-C disease with crisis, unspecified D57.219 D57.80 - Other sickle-cell disorders without crisis - Other sickle-cell disorders with crisis, unspecified D57.819 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm - Thyrotoxicosis with toxic E05.00 - E05.11 single thyroid nodule with thyrotoxic crisis or storm E08.311 - Diabetes mellitus due to underlying condition with unspecified with macular E08.36 edema - Diabetes mellitus due to underlying condition with diabetic cataract E09.311 - Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular E09.36 edema - Drug or chemical induced diabetes mellitus with diabetic cataract E10.311 - Type 1 diabetes mellitus with unspecified diabetic retinopathy with - Type 1 E10.39 diabetes mellitus with other diabetic ophthalmic complication E11.311 - Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 2 E11.39 diabetes mellitus with other diabetic ophthalmic complication E13.311 - Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema - E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E34.1 Other hypersecretion of intestinal hormones E34.8 Other specified endocrine disorders E35 Disorders of endocrine glands in diseases classified elsewhere E50.0 - E50.9 Vitamin A deficiency with conjunctival xerosis - Vitamin A deficiency, unspecified E64.1 Sequelae of vitamin A deficiency Conversion disorder with motor symptom or deficit - Conversion disorder with mixed symptom F44.4 - F44.7 presentation

Printed on 4/26/2016. Page 4 of 9 ICD-10 Codes Description G43.001 - Migraine without aura, not intractable, with status migrainosus - Migraine, unspecified, G43.919 intractable, without status migrainosus Vertebro-basilar artery syndrome - Other vascular syndromes of brain in cerebrovascular G45.0 - G46.8 diseases G93.2 Benign intracranial hypertension H00.011 - Hordeolum externum right upper - Unspecified disorder of eyelid H02.9 H05.00 - H05.9 Unspecified acute inflammation of orbit - Unspecified disorder of orbit H16.001 - Unspecified , right eye - Unspecified keratitis H16.9 H17.00 - H17.9 Adherent leukoma, unspecified eye - Unspecified corneal scar and opacity Unspecified corneal deposit, right eye - Disorders of and in diseases classified H18.001 - H22 elsewhere H25.011 - Cortical age-related cataract, right eye - Unspecified cataract H26.9 H28 Cataract in diseases classified elsewhere H30.001 - Unspecified focal chorioretinal inflammation, right eye - Other intraretinal microvascular H35.09 abnormalities H35.171 - Retrolental fibroplasia, right eye - Secondary vitreoretinal degeneration, unspecified eye H35.469 H35.51 - Vitreoretinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium H35.54 H35.60 - H35.9 Retinal hemorrhage, unspecified eye - Unspecified retinal disorder H40.001 - Preglaucoma, unspecified, right eye - Preglaucoma, unspecified, unspecified eye H40.009 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 H40.042 Steroid responder, left eye H40.043 Steroid responder, bilateral H40.051 , 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 H40.10X0 - Unspecified open-angle glaucoma, stage unspecified - Glaucoma secondary to drugs, bilateral, H40.63X4 indeterminate stage H40.811 - Glaucoma with increased episcleral venous pressure, right eye - Unspecified glaucoma H40.9 H42 Glaucoma in diseases classified elsewhere H44.001 - Unspecified purulent , right eye - Unspecified disorder of H44.9 H46.00 - H47.9 Optic papillitis, unspecified eye - Unspecified disorder of visual pathways H49.00 - H51.9 Third [oculomotor] nerve palsy, unspecified eye - Unspecified disorder of binocular movement H53.001 - Unspecified , right eye - Legal blindness, as defined in USA H54.8 H55.00 - Unspecified - Other irregular eye movements H55.89 H57.8 Other specified disorders of eye and adnexa Nontraumatic intracerebral hemorrhage in hemisphere, subcortical - Occlusion and stenosis of I61.0 - I66.9 unspecified cerebral artery I67.1 - I67.2 Cerebral aneurysm, nonruptured - Cerebral atherosclerosis

Printed on 4/26/2016. Page 5 of 9 ICD-10 Codes Description I67.4 - I67.82 Hypertensive encephalopathy - Cerebral ischemia Reversible cerebrovascular vasoconstriction syndrome - Other cerebrovascular disorders in I67.841 - I68.8 diseases classified elsewhere M31.5 - M31.6 Giant cell arteritis with polymyalgia rheumatica - Other giant cell arteritis Q10.0 - Q10.7 Congenital ptosis - Congenital malformation of orbit Congenital malformation of vitreous humor - Congenital malformation of posterior segment of Q14.0 - Q14.9 eye, unspecified Q15.0 Congenital glaucoma Q85.00 Neurofibromatosis, unspecified Q85.03 Schwannomatosis Q85.09 Other neurofibromatosis R44.1 Visual hallucinations R48.3 Visual agnosia S00.10XA - Contusion of unspecified eyelid and periocular area, initial encounter - Contusion of left eyelid S00.12XS and periocular area, sequela S04.019A - Injury of optic nerve, unspecified eye, initial encounter - Injury of optic nerve, unspecified eye, S04.019S sequela S04.02XA - Injury of optic chiasm, initial encounter - Injury of optic chiasm, sequela S04.02XS S04.031A - Injury of optic tract and pathways, right eye, initial encounter - Injury of optic tract and S04.039S pathways, unspecified eye, sequela S04.041A - Injury of visual cortex, right eye, initial encounter - Injury of visual cortex, unspecified eye, S04.049S sequela S04.10XA - Injury of oculomotor nerve, unspecified side, initial encounter - Injury of oculomotor nerve, left S04.12XS side, sequela S04.20XA - Injury of trochlear nerve, unspecified side, initial encounter - Injury of trochlear nerve, S04.20XS unspecified side, sequela S05.10XA - Contusion of eyeball and orbital tissues, unspecified eye, initial encounter - Contusion of eyeball S05.12XS and orbital tissues, left eye, sequela S05.90XA - Unspecified injury of unspecified eye and orbit, initial encounter - Unspecified injury of S05.90XS unspecified eye and orbit, sequela T15.00XA - Foreign body in , unspecified eye, initial encounter - Foreign body on external eye, part T15.92XS unspecified, left eye, sequela Encounter for follow-up examination after completed treatment for conditions other than Z09 malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy

ICD-10 Codes that DO NOT Support Medical Necessity N/A ICD-10 Additional Information

Back to Top General Information

Associated Information Documentation Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record and available upon request. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

Printed on 4/26/2016. Page 6 of 9 If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and maintain hard copy documentation of test results and interpretation along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in this order for the test.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision FCSO reference LCD number(s) – L29038, L29308, L29487

American Optometric Association. (2002). Care of the patient with diabetes mellitus (3rd ed.). St. Louis, MO. Retrieved October 24, 2005 from www.guideline.gov database (003386).

American Optometric Association. (2002). Care of the patient with open angle glaucoma (2nd ed.). St. Louis, MO. Retrieved October 24, 2005 from www.guideline.gov database (003385).

American Academy of Retina Panel, Preferred Practice Patterns Committee. (2003). Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco, CA. Retrieved October 24, 2005 from www.guideline.gov database (003277). Back to Top Revision History Information

Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row.

Printed on 4/26/2016. Page 7 of 9 Revision Revision Reason(s) for History History Revision History Explanation Change Date Number Revision Number: 3 Publication: January 2016 Connection LCR A/B2015-037 • Revisions Due 10/01/2015 R4 To ICD-10-CM Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis code range H35.51-H35.54 to Code Changes 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 12/28/15, for dates of service on or after 10/01/15. Revision Number: 2 Publication: November 2015 Connection LCR A/B2015-026 • Revisions Due 10/01/2015 R3 To ICD-10-CM Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes E10.39, E11.39, Code Changes E13.39, Z09, Z79.3, Z79.891, and Z79.899 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 11/12/15, for dates of service on or after 10/01/15. Revision Number: 1 Publication: October 2015 Connection LCR A/B2015-016 • Revisions Due 10/01/2015 R2 To ICD-10-CM Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes H40.001-H40.009 Code Changes H40.011,H40.012,H40.013,H40.021,H40.022,H40.023,H40.031,H40.032,H40.033,H40.041,H40.042 H40.043,H40.051,H40.052,H40.053,H40.061,H40.062, and H40.063 to the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is based on date of service. The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM • Provider 10/01/2015 R1 LCD’s language and coding. Education/Guidance

Printed on 4/26/2016. Page 8 of 9 Back to Top Associated Documents

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Printed on 4/26/2016. Page 9 of 9