Local Coverage Determination (LCD): Electroretinography (ERG) (L37371)

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Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s) Novitas Solutions, Inc. A and B MAC 04111 - MAC A J - H Colorado Novitas Solutions, Inc. A and B MAC 04112 - MAC B J - H Colorado Novitas Solutions, Inc. A and B MAC 04211 - MAC A J - H New Mexico Novitas Solutions, Inc. A and B MAC 04212 - MAC B J - H New Mexico Novitas Solutions, Inc. A and B MAC 04311 - MAC A J - H Oklahoma Novitas Solutions, Inc. A and B MAC 04312 - MAC B J - H Oklahoma Novitas Solutions, Inc. A and B MAC 04411 - MAC A J - H Texas Novitas Solutions, Inc. A and B MAC 04412 - MAC B J - H Texas Colorado New Mexico Novitas Solutions, Inc. A and B MAC 04911 - MAC A J - H Oklahoma Texas Novitas Solutions, Inc. A and B MAC 07101 - MAC A J - H Arkansas Novitas Solutions, Inc. A and B MAC 07102 - MAC B J - H Arkansas Novitas Solutions, Inc. A and B MAC 07201 - MAC A J - H Louisiana Novitas Solutions, Inc. A and B MAC 07202 - MAC B J - H Louisiana Novitas Solutions, Inc. A and B MAC 07301 - MAC A J - H Mississippi Novitas Solutions, Inc. A and B MAC 07302 - MAC B J - H Mississippi Novitas Solutions, Inc. A and B MAC 12101 - MAC A J - L Delaware Novitas Solutions, Inc. A and B MAC 12102 - MAC B J - L Delaware Novitas Solutions, Inc. A and B MAC 12201 - MAC A J - L District of Columbia Novitas Solutions, Inc. A and B MAC 12202 - MAC B J - L District of Columbia Novitas Solutions, Inc. A and B MAC 12301 - MAC A J - L Maryland Novitas Solutions, Inc. A and B MAC 12302 - MAC B J - L Maryland Novitas Solutions, Inc. A and B MAC 12401 - MAC A J - L New Jersey Novitas Solutions, Inc. A and B MAC 12402 - MAC B J - L New Jersey Novitas Solutions, Inc. A and B MAC 12501 - MAC A J - L Pennsylvania Novitas Solutions, Inc. A and B MAC 12502 - MAC B J - L Pennsylvania District of Columbia Delaware Novitas Solutions, Inc. A and B MAC 12901 - MAC A J - L Maryland New Jersey Pennsylvania Back to Top LCD Information

Document Information

LCD ID Original Effective Date L37371 For services performed on or after 01/25/2018

LCD Title Revision Effective Date Electroretinography (ERG) For services performed on or after 05/10/2018

Printed on 5/14/2018. Page 1 of 27 Proposed LCD in Comment Period Revision Ending Date N/A N/A

Source Proposed LCD Retirement Date DL37371 N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement Notice Period Start Date CPT only copyright 2002-2018 American Medical 12/07/2017 Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Notice Period End Date Applicable FARS/DFARS Apply to Government Use. Fee 01/24/2018 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 recommending their use. The AMA does not directly or 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.

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 This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for electroretinography (ERG). 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 electroretinography (ERG) 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 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 310.1 Routine Costs in Clinical Trials • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure codes • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1 Reasonable and Necessary Provisions in LCDs • CMS IOM Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Correct Coding Initiative

Social Security Act (Title XVIII) Standard References:

Printed on 5/14/2018. Page 2 of 27 • 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. • 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.

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 policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

The full field electroretinogram (ERG) is used to detect loss of retinal function or distinguish between retinal and optic nerve lesions. ERG measures the electrical activity generated by neural and non-neuronal cells in the in response to a light . ERGs are usually obtained using electrodes embedded in a corneal , or a thin wire inside the lower , which measure a summation of retinal electrical activity at the corneal surface. The International Society for Clinical of Vision (ISCEV) introduced minimum standards for the ERG in 1989. The ERG helps to distinguish retinal degeneration and dystrophies.The focal or foveal ERG (fERG) is useful in providing information regarding diseases limited to the macula. Multi-focal electroretinography (mfERG) is a higher resolution form of ERG, enabling assessment of ERG activity in small areas of the retina. Pattern ERG (PERG) uses pattern-reversal stimuli and is used to detect subtle optic neuropathies.

ERG in

A 2011 report by the American Academy of (AAO) on “Assessment of Visual Function in Glaucoma” noted that while ERG, as objective measures of visual function, provided testing free of patient input, issues prevent their adoption for glaucoma management. It concluded that advances in technology have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time and that further research on an objective measure of visual function is needed.

Since then several studies have investigated the use of ERG technology to differentiate between normal healthy and eyes with early to advanced visual field loss resulting from glaucoma. The authors indicated that ERG may allow earlier diagnosis of glaucoma. However, Novitas has determined that without larger studies, AAO’s 2011 conclusion, that ERG’s have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time, remains. This was also the conclusion of a 2013 study which prospectively monitored progressive changes of RGC function in early glaucoma using PERG. The authors concluded that further follow-up is required to determine whether PERG losses are predictors of future visual field loss.

Neither of the 2015 AAO Preferred Practice Guidelines, “Primary Open-Angle Glaucoma Suspect” or “Primary Open-Angle Glaucoma,” mention ERG as a diagnostic tool.

There remain no verified guidelines for normal vs. abnormal that would be easily applicable to an individual patient. Novitas, therefore, considers the use of ERG for either glaucoma diagnosis or management investigational.

Covered Indications

1. To diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions. Note: There are multiple retinal conditions that would be considered covered indications that may not be listed below. For a complete listing of covered diagnoses, please refer to the “ICD-10 Codes that Support Medical Necessity” section.

Printed on 5/14/2018. Page 3 of 27 • Toxic retinopathies, including those caused by intraocular metallic foreign bodies, Vigabatrin and Chlorpromazine • • Retinal vascular disease (e.g., Central Retinal Artery Occlusion [CRAO], Central Retinal Vein Occlusion [CRVO], Branch Vein Occlusion [BVO], and ) • Autoimmune retinopathies (e.g., Cancer Associated Retinopathy [CAR], Melanoma Associated Retinopathy [MAR], and Acute Zonal Occult Outer Retinopathy [AZOOR]) • • Assessment of retinal function after trauma (e.g., vitreous hemorrhage, dense cataracts, and other conditions where the fundus cannot be visualized) • and related hereditary degenerations • Retinitis punctata albescens • Leber's congenital amaurosis • • Gyrate atrophy of the retina and choroid • Goldman-Favre syndrome • Congenital stationary night blindness • X-linked juvenile • • • Disorders mimicking retinitis pigmentosa • • Retinal Dystrophies (e.g., Stargardt’s disease, Fundus Flavimaculata, North Carolina macular dystrophy, Best’s Vitelliform dystrophy, Sorsby’s macular dystrophy)

2. To detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity (mfERG) per AAO guidelines, which does not recommend mfERG for routine primary screening, but can provide objective confirmation of suspected visual loss.

Limitations

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

1. The use of ERG for glaucoma (either diagnosis or management) is considered experimental and investigational as the available published clinical evidence does not support clinical value. Therefore, the use of ERG, (all forms: ERG, fERG, mfERG, PERG, etc.) for glaucoma is non-covered and will be denied as not reasonable and necessary.

Provider Qualifications

Diagnostic ERG testing must be performed under the general supervision of and interpreted by a qualified physician as follows:

• General Supervision - means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under General Supervision, the training of the non-physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

• Qualified Physicians must possess evidence of knowledge, training, and expertise to perform and interpret these tests. This training and expertise must have been acquired within the framework of an accredited school, residency or fellowship program.

Place of Services (POS)

For additional information on services performed in an Independent Diagnostic Testing Facility (IDTF), please refer to Local Coverage Determination (LCD) L35448 Independent Diagnostic Testing Facility (IDTF) and Local Coverage Article A53252 Independent Diagnostic Testing Facility (IDTF).

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Printed on 5/14/2018. Page 4 of 27 However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, 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 100-08, Chapter 13, Section 13.5.1, 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). • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: ◦ 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. ◦ 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

Please refer to the “History/Background and/or General Information” section for general information on ERG including full field ERG, focal ERG, multi-focal ERG, and pattern ERG.

Multiple sources of literature (Bach et al. [2013]; Barrett et al. [2014]; CK et al. [2011]; Creel; Hood et al. [2012]; Incesu [2013]; International Society for Clinical Electrophysiology of Vision [ISCEV]; Jacobs; John et al. [2009]; Kumar et al.; Maa et al. [2016]; Marmor et al. [2016]; McBain et al. [2007]; McCulloch et al. [2015]; Perlman; Whatham et al. [2014]) were submitted for consideration. These were mostly descriptive of how ERG should be performed, the history of the testing procedures involved with ERG and sources for the “Covered Indications” section.

This is a new LCD for Novitas JH and JL developed as a national MAC LCD workgroup collaboration based on information from data analysis revealing that a significant percentage of the diagnoses reported on ERG claims contained some form of a glaucoma diagnosis. These findings were not consistent with current literature and guideline recommendations for ERG use.

The following is a summary of the evidence for exclusion of glaucoma-related diagnoses for testing by ERG (except glaucomatous optic atrophy):

A) Evidence-Based Guidelines

• The American Academy of Ophthalmology (AAO) Glaucoma Preferred Practice Pattern Panel of 2014-2015 included reviewers from the Ophthalmic Technology Assessment Committee Glaucoma Panel, Practicing Ophthalmologists Advisory Committee for Education and reviewers from the American Academy of Family Physicians, American College of Physicians, American College of Surgeons, American Glaucoma Society, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Association of University Professors of Ophthalmology, Glaucoma Research Foundation, National Institute, plus multiple other international and national societies. The Preferred Practice Pattern Panel did not include ERG in their diagnostic testing recommendations. The diagnostic tests included by the panel are central corneal thickness (CCT) measurement, visual field evaluation and optic nerve head (ONH) and retinal nerve fiber layer (RNFL) imaging. There are 598 references listed for Primary Open-Angle Glaucoma and 230 references listed for Primary Open-Angle Glaucoma Suspect with ratings based on the Scottish Intercollegiate Guideline Network and the GRADE group within the documents.

Printed on 5/14/2018. Page 5 of 27 • In addition, the American Optometric Association (AOA), in their clinical practice guideline on the care of the patient with open-angle glaucoma (last revised in 2010), did not include ERG in their diagnostic testing recommendations.

• Jampel, et al. conducted a literature review for an ophthalmic technology assessment of visual function in glaucoma, which was published by the AAO in 2011, and concluded that advances in technology (including ERG) have yet to produce definitive guidance in the diagnosis of glaucoma or its progression over time and further research on an objective measure of visual function is needed. Listed were 81 references with a grading system and strength of evidence.

B) Systematic Review

• Lai, et al. (2007) conducted a systematic review for the clinical applications of mfERG. The conclusions were mfERG is not very reliable in the detection and monitoring of functional loss caused by glaucoma, second-order kernel mfERG responses are not very useful in investigating glaucomatous damage, the use of mfERG s-wave in assessing glaucomatous damage remains uncertain, and the sensitivity of mfERG in detecting retinal dysfunction in ocular hypertension (OHT) patients remains questionable. Listed were 329 references with limitations of the studies discussed within the review article.

C) Observational Studies

• Bach, et al. (2006), in a prospective cohort study conducted in Germany, followed 54 subjects with OHT for at least three years (median follow-up of 8.2 years) using PERG and visual field testing at six month intervals. Glaucoma developed in five subjects. The median age of the subjects was 52 years. Pressure- lowering treatment (eye drops, laser, laser + eye drops and ) was received by 82% of the subjects at some point during the study. The study results found that one year before conversion, the receiver-operating characteristic (ROC) area of the PERG ratio was 0.78. At a threshold of 1.06, this corresponded to a sensitivity of 80%, a specificity of 71%, a positive predictive value of 23%, and a negative predictive value of 97%. The study conclusion was PERG can help to predict stability or progression to glaucoma in OHT at least one year prior to conversion.

Bode, et al. (2011) was a continuation of the Bach, et al. (2006) prospective cohort study in Germany. The study followed 64 subjects with OHT for at least three years (mean of 10.3 years). The median age of the subjects was 60.6 years. The study conclusion was PERG, especially the PERG ratio, detected glaucoma patients four years before visual field changes occurred, with a sensitivity of 75% and specificity of 76%.

The quality of evidence for these studies is low due to the small study sizes, problems with interpretation due to the fact that treatment probably distorted the natural course, and the studies were not generalizable to a Medicare population.

• Banitt, et al. (2013), in a prospective cohort study, followed 107 glaucoma suspect subjects for at least four years using PERG, optical coherence tomography (OCT) of the RNFL and standard automated perimetry testing at six month intervals . The mean age of the subjects was 56.1 +/- 10.1 years. A total of 56 subjects received pressure-lowering medications at some point during the study. The study conclusion was PERG signal anticipates an equivalent loss of OCT signal by several years. The quality of evidence for this study is low due to the small study size, shifts in intraocular pressure (IOP) could have led to overestimation or underestimation of PERG loss rates, and the study was not generalizable to a Medicare population.

• Jafarzadehpour, et al. (2013), in a prospective case control study in Iran, tested 20 glaucoma suspect, 15 early primary open angle glaucoma (POAG) and 16 normal control subjects using PERG. Responses were recorded to 0.8 degree and 16 degree black and white checkerboard stimuli. One of the exclusion criteria for the study was age greater than 65 years. The study conclusion was PERG may detect (RGC) dysfunction (increased latency) before cell death (decreased amplitude) occurs. The quality of evidence for this study is low due to the small study size and the study was not generalizable to a Medicare population.

Printed on 5/14/2018. Page 6 of 27 • Nesher and Trick (1991) performed a retrospective analysis on the transient and steady-state PERG recorded from 205 subjects. The subjects were divided into 42 with glaucoma, 13 with senile dementia of Alzheimer’s type, 58 with diabetes mellitus (27 without retinopathy and 31 with retinopathy) and 92 control subjects. The mean age of the glaucoma subjects was 56.8 +/- 9.8 years. The analysis found inconsistency in the glaucoma subjects’ results when compared to a study by Holder published in 1989. The study conclusion was a recommendation to record the PERG under both transient and steady-state conditions to optimize the clinical utility of the procedure. The quality of evidence for this study is low due to the small study size, the results for the glaucoma patients was inconsistent with a previous study, and the study was not generalizable to a Medicare population.

• Tafreshi, et al. (2010), in a cross-sectional study, performed PERG, standard automated perimetry (SAP), short-wavelength automated perimetry (SWAP), and frequency-doubling technology (FDT) on 42 healthy subjects and 54 glaucoma subjects. The average age of the healthy subjects was 63.6 years and the average age of the glaucoma subjects was 70.4 years. The study conclusions were the diagnostic accuracy of PERG amplitude was similar to SAP and SWAP, but worse than FDT. Also, PERG may hold some advantage over psychophysical testing because of its largely objective nature. The quality of the evidence is low due to the small study size and the study did not demonstrate an improvement in health outcomes for the Medicare population.

• Ventura, et al. (2005), in a cross-sectional study, performed PERG, SAP, and vertical cup-to-disc ratios (C/D) on 200 glaucoma suspect (GS) subjects, 42 early manifestation glaucoma (EMG) subjects and 114 control subjects. The mean age of the GS and EMG subjects was 57 +/- 13 years. The mean age of the control subjects was 46.4 +/- 18.2 years. The study conclusion was the correlation between PERG abnormality and known risk factors for glaucoma indicates that PERG has a predictive potential for the development or progression of glaucoma, or both. The quality of evidence for this study is low due to the study was not generalizable to a Medicare population.

• Ventura, et al. (2013), in a prospective cohort study, followed 59 glaucoma suspect subjects for 5.7 +/- 1.4 years using PERG and SAP two times per year. The age of the subjects was not reported in the study. None of the subjects received intraocular pressure-lowering medications at any point during the study. The study conclusion was that it remains to be established whether PERG progression has predictive value for developing visual dysfunction. The quality of evidence for this study is low due to the small study size and the study was not generalizable to a Medicare population.

Analysis of Evidence (Rationale for Determination)

The use of ERG to diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions is supported in the literature for a wide variety of conditions (e.g. toxic, diabetic and autoimmune retinopathies, retinal vascular disease, retinal detachment and/or trauma, hereditary or congenital retinal diseases).

The quality of evidence for the observational studies for ocular hypertension, glaucoma suspect and glaucoma is low due to the small study sizes, the studies were not generalizable to a Medicare population, and the studies did not demonstrate an improvement in health outcomes for the Medicare population. Evidence based guidelines from the American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) did not support the use of ERG for these conditions. Based on the weak strength of study evidence and the absence of sound data to support the clinical utility of ERG for ocular hypertension, glaucoma suspect, or glaucoma, there is little evidence to support the use of ERG in the Medicare population for these conditions.

* This analysis used the American College of Physicians (ACP) Guideline Grading System as the basis for grading the quality of evidence and analyzing the evidence.

Back to Top Coding Information

Bill Type Codes:

Printed on 5/14/2018. Page 7 of 27 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.

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.

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: 92275 Electroretinography

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 92275:

Group 1 Codes: ICD-10 Description Codes A18.53 Tuberculous chorioretinitis D18.09* Hemangioma of other sites Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular E08.311 edema Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular E08.319 edema Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E08.3211 macular edema, right eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E08.3212 macular edema, left eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E08.3213 macular edema, bilateral Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E08.3291 macular edema, right eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E08.3292 macular edema, left eye Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E08.3293 macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3311 with macular edema, right eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3312 with macular edema, left eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3313 with macular edema, bilateral Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3391 without macular edema, right eye E08.3392 Printed on 5/14/2018. Page 8 of 27 ICD-10 Description Codes Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.3393 without macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E08.3411 macular edema, right eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E08.3412 macular edema, left eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E08.3413 macular edema, bilateral Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy E08.3491 without macular edema, right eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy E08.3492 without macular edema, left eye Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy E08.3493 without macular edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E08.3511 edema, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E08.3512 edema, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E08.3513 edema, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3521 retinal detachment involving the macula, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3522 retinal detachment involving the macula, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3523 retinal detachment involving the macula, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3531 retinal detachment not involving the macula, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3532 retinal detachment not involving the macula, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E08.3533 retinal detachment not involving the macula, bilateral Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E08.3541 traction retinal detachment and rhegmatogenous retinal detachment, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E08.3542 traction retinal detachment and rhegmatogenous retinal detachment, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E08.3543 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 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E08.3591 edema, right eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E08.3592 edema, left eye Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E08.3593 edema, bilateral Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular E09.311 edema Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular E09.319 edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with E09.3211 macular edema, right eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with E09.3212 macular edema, left eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with E09.3213 macular edema, bilateral Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E09.3291 macular edema, right eye Printed on 5/14/2018. Page 9 of 27 ICD-10 Description Codes E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E09.3293 macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E09.3311 macular edema, right eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E09.3312 macular edema, left eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E09.3313 macular edema, bilateral Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy E09.3391 without macular edema, right eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy E09.3392 without macular edema, left eye Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy E09.3393 without macular edema, bilateral Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E09.3411 macular edema, right eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E09.3412 macular edema, left eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E09.3413 macular edema, bilateral Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E09.3491 macular edema, right eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E09.3492 macular edema, left eye Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E09.3493 macular edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular E09.3511 edema, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular E09.3512 edema, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular E09.3513 edema, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3521 retinal detachment involving the macula, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3522 retinal detachment involving the macula, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3523 retinal detachment involving the macula, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3531 retinal detachment not involving the macula, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3532 retinal detachment not involving the macula, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction E09.3533 retinal detachment not involving the macula, bilateral Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E09.3541 traction retinal detachment and rhegmatogenous retinal detachment, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E09.3542 traction retinal detachment and rhegmatogenous retinal detachment, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E09.3543 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 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E09.3591 edema, right eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E09.3592 edema, left eye Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E09.3593 edema, bilateral Printed on 5/14/2018. Page 10 of 27 ICD-10 Description Codes E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E10.3211 eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E10.3212 eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E10.3213 bilateral Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E10.3291 right eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E10.3292 eye Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E10.3293 bilateral Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E10.3311 right eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E10.3312 left eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E10.3313 bilateral Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E10.3391 edema, right eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E10.3392 edema, left eye Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E10.3393 edema, bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E10.3411 eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E10.3412 eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E10.3413 bilateral Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E10.3491 right eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E10.3492 left eye Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E10.3493 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 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E10.3521 involving the macula, right eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E10.3522 involving the macula, left eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E10.3523 involving the macula, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E10.3531 involving the macula, right eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E10.3532 involving the macula, left eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E10.3533 involving the macula, bilateral Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E10.3541 detachment and rhegmatogenous retinal detachment, right eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E10.3542 detachment and rhegmatogenous retinal detachment, left eye Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E10.3543 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 Printed on 5/14/2018. Page 11 of 27 ICD-10 Description Codes 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 E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E11.3211 eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E11.3212 eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E11.3213 bilateral Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E11.3291 right eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E11.3292 eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E11.3293 bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E11.3311 right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E11.3312 left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E11.3313 bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E11.3391 edema, right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E11.3392 edema, left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E11.3393 edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E11.3411 eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E11.3412 eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E11.3413 bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E11.3491 right eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E11.3492 left eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E11.3493 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 E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E11.3521 involving the macula, right eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E11.3522 involving the macula, left eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E11.3523 involving the macula, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E11.3531 involving the macula, right eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E11.3532 involving the macula, left eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E11.3533 involving the macula, bilateral Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E11.3541 detachment and rhegmatogenous retinal detachment, right eye Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E11.3542 detachment and rhegmatogenous retinal detachment, left eye Printed on 5/14/2018. Page 12 of 27 ICD-10 Description Codes Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E11.3543 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 E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E13.3211 edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E13.3212 edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E13.3213 edema, bilateral Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E13.3291 edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E13.3292 edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E13.3293 edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E13.3311 edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E13.3312 edema, left eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E13.3313 edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without E13.3391 macular edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without E13.3392 macular edema, left eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without E13.3393 macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E13.3411 edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E13.3412 edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E13.3413 edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E13.3491 edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E13.3492 edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E13.3493 edema, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E13.3511 eye E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, E13.3513 bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3521 detachment involving the macula, right eye Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3522 detachment involving the macula, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3523 detachment involving the macula, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3531 detachment not involving the macula, right eye E13.3532

Printed on 5/14/2018. Page 13 of 27 ICD-10 Description Codes Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal E13.3533 detachment not involving the macula, bilateral Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction E13.3541 retinal detachment and rhegmatogenous retinal detachment, right eye Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction E13.3542 retinal detachment and rhegmatogenous retinal detachment, left eye Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction E13.3543 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 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, E13.3591 right eye Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E13.3592 eye Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, E13.3593 bilateral E50.5 Vitamin A deficiency with night blindness E50.9 Vitamin A deficiency, unspecified F44.6 Conversion disorder with sensory symptom or deficit G45.3 Amaurosis fugax H15.031 Posterior scleritis, right eye H15.032 Posterior scleritis, left eye H15.033 Posterior scleritis, bilateral H20.011 Primary iridocyclitis, right eye H20.012 Primary iridocyclitis, left eye H20.013 Primary iridocyclitis, bilateral H30.001 Unspecified focal chorioretinal inflammation, right eye H30.002 Unspecified focal chorioretinal inflammation, left eye H30.003 Unspecified focal chorioretinal inflammation, bilateral 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 H30.101 Unspecified disseminated chorioretinal inflammation, right eye H30.102 Unspecified disseminated chorioretinal inflammation, left eye H30.103 Unspecified disseminated chorioretinal inflammation, 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

Printed on 5/14/2018. Page 14 of 27 ICD-10 Description Codes 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 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 H30.91 Unspecified chorioretinal inflammation, right eye H30.92 Unspecified chorioretinal inflammation, left eye H30.93 Unspecified chorioretinal inflammation, bilateral H31.001 Unspecified chorioretinal scars, right eye H31.002 Unspecified chorioretinal scars, left eye H31.003 Unspecified chorioretinal scars, bilateral H31.011 Macula scars of posterior pole (postinflammatory) (post-traumatic), right eye H31.012 Macula scars of posterior pole (postinflammatory) (post-traumatic), left eye H31.013 Macula scars of posterior pole (postinflammatory) (post-traumatic), bilateral H31.021 Solar retinopathy, right eye H31.022 Solar retinopathy, left eye H31.023 Solar retinopathy, bilateral H31.091 Other chorioretinal scars, right eye H31.092 Other chorioretinal scars, left eye H31.093 Other chorioretinal scars, 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 H31.20 Hereditary choroidal dystrophy, unspecified H31.21 Choroideremia H31.22 Choroidal dystrophy (central areolar) (generalized) (peripapillary) H31.23 Gyrate atrophy, choroid H31.29 Other hereditary choroidal dystrophy H31.301 Unspecified choroidal hemorrhage, right eye H31.302 Unspecified choroidal hemorrhage, left eye H31.303 Unspecified choroidal hemorrhage, bilateral H31.311 Expulsive choroidal hemorrhage, right eye H31.312 Expulsive choroidal hemorrhage, left eye H31.313 Expulsive choroidal hemorrhage, bilateral H31.321 Choroidal rupture, right eye H31.322 Choroidal rupture, left eye H31.323 Choroidal rupture, bilateral H31.401 Unspecified choroidal detachment, right eye H31.402 Unspecified choroidal detachment, left eye H31.403 Unspecified choroidal detachment, 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 H33.001 Unspecified retinal detachment with retinal break, right eye Printed on 5/14/2018. Page 15 of 27 ICD-10 Description Codes H33.002 Unspecified retinal detachment with retinal break, left eye H33.003 Unspecified retinal detachment with retinal break, bilateral 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 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 H33.101 Unspecified retinoschisis, right eye H33.102 Unspecified retinoschisis, left eye H33.103 Unspecified retinoschisis, 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 H33.301 Unspecified retinal break, right eye H33.302 Unspecified retinal break, left eye H33.303 Unspecified retinal break, 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 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

Printed on 5/14/2018. Page 16 of 27 ICD-10 Description Codes 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 H34.9 Unspecified retinal vascular occlusion H35.00 Unspecified background retinopathy 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 H35.101 Retinopathy of prematurity, unspecified, right eye H35.102 Retinopathy of prematurity, unspecified, left eye H35.103 Retinopathy of prematurity, unspecified, bilateral H35.111 Retinopathy of prematurity, stage 0, right eye H35.112 Retinopathy of prematurity, stage 0, left eye H35.113 Retinopathy of prematurity, stage 0, bilateral H35.121 Retinopathy of prematurity, stage 1, right eye H35.122 Retinopathy of prematurity, stage 1, left eye H35.123 Retinopathy of prematurity, stage 1, bilateral H35.131 Retinopathy of prematurity, stage 2, right eye H35.132 Retinopathy of prematurity, stage 2, left eye H35.133 Retinopathy of prematurity, stage 2, bilateral H35.141 Retinopathy of prematurity, stage 3, right eye Printed on 5/14/2018. Page 17 of 27 ICD-10 Description Codes H35.142 Retinopathy of prematurity, stage 3, left eye H35.143 Retinopathy of prematurity, stage 3, bilateral H35.151 Retinopathy of prematurity, stage 4, right eye H35.152 Retinopathy of prematurity, stage 4, left eye H35.153 Retinopathy of prematurity, stage 4, bilateral H35.161 Retinopathy of prematurity, stage 5, right eye H35.162 Retinopathy of prematurity, stage 5, left eye H35.163 Retinopathy of prematurity, stage 5, bilateral 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 H35.30 Unspecified 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 without subfoveal H35.3113 involvement Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal H35.3114 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 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal H35.3123 involvement Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal H35.3124 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 Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal H35.3133 involvement Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal H35.3134 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 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

Printed on 5/14/2018. Page 18 of 27 ICD-10 Description Codes 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 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 H36 Retinal disorders in diseases classified elsewhere 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 Printed on 5/14/2018. Page 19 of 27 ICD-10 Description Codes 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 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 H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.8 Other optic neuritis H46.9 Unspecified optic neuritis H47.011 Ischemic optic neuropathy, right eye H47.012 Ischemic optic neuropathy, left eye H47.013 Ischemic optic neuropathy, bilateral H47.021 Hemorrhage in optic nerve sheath, right eye H47.022 Hemorrhage in optic nerve sheath, left eye H47.023 Hemorrhage in optic nerve sheath, bilateral H47.031 Optic nerve hypoplasia, right eye H47.032 Optic nerve hypoplasia, left eye H47.033 Optic nerve hypoplasia, bilateral H47.091 Other disorders of optic nerve, not elsewhere classified, right eye H47.092 Other disorders of optic nerve, not elsewhere classified, left eye H47.093 Other disorders of optic nerve, not elsewhere classified, bilateral H47.10 Unspecified papilledema 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 H47.20 Unspecified optic atrophy H47.211 Primary optic atrophy, right eye H47.212 Primary optic atrophy, left eye H47.213 Primary optic atrophy, bilateral H47.22 Hereditary optic atrophy H47.231 Glaucomatous optic atrophy, right eye H47.232 Glaucomatous optic atrophy, left eye 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 H47.311 Coloboma of optic disc, right eye H47.312 Coloboma of optic disc, left eye H47.313 Coloboma of optic disc, 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 H53.10 Unspecified subjective visual disturbances

Printed on 5/14/2018. Page 20 of 27 ICD-10 Description Codes H53.11 Day blindness H53.121 Transient visual loss, right eye H53.122 Transient visual loss, left eye H53.123 Transient visual loss, bilateral H53.131 Sudden visual loss, right eye H53.132 Sudden visual loss, left eye H53.133 Sudden visual loss, bilateral H53.15 Visual distortions of shape and size H53.16 Psychophysical visual disturbances H53.19 Other subjective visual disturbances H53.411 Scotoma involving central area, right eye H53.412 Scotoma involving central area, left eye H53.413 Scotoma involving central area, 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 H53.51 Achromatopsia H53.52 Acquired color vision deficiency H53.60 Unspecified night blindness H53.61 Abnormal dark adaptation curve H53.62 Acquired night blindness H53.63 Congenital night blindness H53.69 Other night blindness H53.71 Glare sensitivity H53.72 Impaired contrast sensitivity H53.8 Other visual disturbances H53.9 Unspecified visual disturbance H54.0X33 Blindness right eye category 3, blindness left eye category 3 H54.0X34 Blindness right eye category 3, blindness left eye category 4 H54.0X35 Blindness right eye category 3, blindness left eye category 5 H54.0X43 Blindness right eye category 4, blindness left eye category 3 H54.0X44 Blindness right eye category 4, blindness left eye category 4 H54.0X45 Blindness right eye category 4, blindness left eye category 5 H54.0X53 Blindness right eye category 5, blindness left eye category 3 H54.0X54 Blindness right eye category 5, blindness left eye category 4 H54.0X55 Blindness right eye category 5, blindness left eye category 5 H54.1131 Blindness right eye category 3, low vision left eye category 1 H54.1132 Blindness right eye category 3, low vision left eye category 2 H54.1141 Blindness right eye category 4, low vision left eye category 1 H54.1142 Blindness right eye category 4, low vision left eye category 2 H54.1151 Blindness right eye category 5, low vision left eye category 1 H54.1152 Blindness right eye category 5, low vision left eye category 2 H54.1213 Low vision right eye category 1, blindness left eye category 3 H54.1214 Low vision right eye category 1, blindness left eye category 4 H54.1215 Low vision right eye category 1, blindness left eye category 5 H54.1223 Low vision right eye category 2, blindness left eye category 3 H54.1224 Low vision right eye category 2, blindness left eye category 4 H54.1225 Low vision right eye category 2, blindness left eye category 5 H54.2X11 Low vision right eye category 1, low vision left eye category 1 H54.2X12 Low vision right eye category 1, low vision left eye category 2 H54.2X21 Low vision right eye category 2, low vision left eye category 1 H54.2X22 Low vision right eye category 2, low vision left eye category 2 H54.413A Blindness right eye category 3, normal vision left eye H54.414A Blindness right eye category 4, normal vision left eye H54.415A Blindness right eye category 5, normal vision left eye H54.42A3 Blindness left eye category 3, normal vision right eye H54.42A4 Blindness left eye category 4, normal vision right eye H54.42A5 Blindness left eye category 5, normal vision right eye Printed on 5/14/2018. Page 21 of 27 ICD-10 Description Codes H54.511A Low vision right eye category 1, normal vision left eye H54.512A Low vision right eye category 2, normal vision left eye H54.52A1 Low vision left eye category 1, normal vision right eye H54.52A2 Low vision left eye category 2, normal vision right eye H54.7 Unspecified visual loss S04.011A Injury of optic nerve, right eye, initial encounter S04.011D Injury of optic nerve, right eye, subsequent encounter S04.011S Injury of optic nerve, right eye, sequela S04.012A Injury of optic nerve, left eye, initial encounter S04.012D Injury of optic nerve, left eye, subsequent encounter S04.012S Injury of optic nerve, left eye, sequela S05.51XA Penetrating wound with foreign body of right eyeball, initial encounter S05.51XD Penetrating wound with foreign body of right eyeball, subsequent encounter S05.51XS Penetrating wound with foreign body of right eyeball, sequela S05.52XA Penetrating wound with foreign body of left eyeball, initial encounter S05.52XD Penetrating wound with foreign body of left eyeball, subsequent encounter S05.52XS Penetrating wound with foreign body of left eyeball, sequela Z79.899* Other long term (current) drug therapy Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *Note: D18.09 is to be reported for “retinal” hemangioma.

*Note: Z79.899 is to be reported for patients receiving vigabatrin, chlorpromazine, chloroquine or hydroxychloroquine being evaluated for retinal toxicity.

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 policy.

Group 1 Codes: ICD-10 Codes Description XX000 Not Applicable

ICD-10 Additional Information N/A Back to Top General Information

Associated Information Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 2. 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. 3. 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. 4. The medical record documentation must support the medical necessity of the services as directed in this policy. 5. The medical record must include the test results. Documentation should also reflect how the test results were used in the patient’s plan of care. 6. When reporting ICD-10 code Z79.899, the medical record must reflect the medication administered as well as the underlying condition for which it was given.

Utilization Guidelines

Printed on 5/14/2018. Page 22 of 27 In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Sources of Information

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

Bibliography

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Ventura LM, Porciatti V, Ishida K, et al. Pattern Electroretinogram Abnormality and Glaucoma. Ophthalmology. 2005 Jan; 112(1): 10–19.

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Other Contractor's Policies

Noridian Draft LCD Visual Electrophysiology Testing (DL37114 and DL37116).

National Government Services Draft LCD Visual Electrophysiology Testing (DL36831).

National Government Services LCD Visual Electrophysiology Testing (L36831).

Wisconsin Physicians Service Insurance Corporation Draft LCD Visual Electrophysiology Testing (DL37015).

Contractor Medical Directors

Back to Top Revision History Information

Revision Revision Reason(s) for History Revision History Explanation History Date Change Number LCD revised and published on 05/10/2018. Non-coverage reaffirmed and several sources added from a reconsideration request for consideration of PERG as covered diagnostic test for glaucoma (ICD-10 codes H40-H42). The coverage content of the LCD has not been changed in response to the reconsideration request.

• Reconsideration 05/10/2018 R1 Additional revision includes update to the SSA references in the Request “CMS National Coverage Policy” section.

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; therefore, not all the fields included on the LCD are applicable as noted in this policy. Back to Top Associated Documents

Attachments N/A

Related Local Coverage Documents Article(s) A53252 - Independent Diagnostic Testing Facility (IDTF) A55809 - Response to Comments: Electroretinography (ERG) LCD(s) DL37371 - Electroretinography (ERG) L35448 - Independent Diagnostic Testing Facility (IDTF) Printed on 5/14/2018. Page 26 of 27 Related National Coverage Documents N/A

Public Version(s) Updated on 05/04/2018 with effective dates 05/10/2018 - N/A Updated on 12/01/2017 with effective dates 01/25/2018 - N/A Back to Top Keywords

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Printed on 5/14/2018. Page 27 of 27