Contractor Information. LCD Information. Local Coverage Determination (LCD): Ophthalmic Angiography (Fluorescein and Indocyanine Green) (L34426)

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1 Local Coverage Determination (LCD): Ophthalmic Angiography (Fluorescein and Indocyanine Green) (L34426) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Palmetto GBA A and B MAC MAC A J - J Alabama Palmetto GBA A and B MAC MAC A J - J Georgia Palmetto GBA A and B MAC MAC A J - J Tennessee Palmetto GBA A and B and HHH MAC MAC A J - M South Carolina Palmetto GBA A and B and HHH MAC MAC B J - M South Carolina Palmetto GBA A and B and HHH MAC MAC A J - M Virginia Palmetto GBA A and B and HHH MAC MAC B J - M Virginia Palmetto GBA A and B and HHH MAC MAC A J - M West Virginia Palmetto GBA A and B and HHH MAC MAC B J - M West Virginia Palmetto GBA A and B and HHH MAC MAC A J - M North Carolina Palmetto GBA A and B and HHH MAC MAC B J - M North Carolina Back to Top LCD Information Document Information LCD ID L34426 Original ICD-9 LCD ID L31557 LCD Title Ophthalmic Angiography (Fluorescein and Indocyanine Green) Proposed LCD in Comment Period N/A Source Proposed LCD N/A AMA CPT / ADA CDT / AHA NUBC Copyright Statement Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/29/2018 Revision Ending Date 02/25/2018 Retirement Date N/A Notice Period Start Date 09/08/2016 Notice Period End Date 10/23/2016 Printed on 1/29/2018. Page 1 of 24

2 CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee 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 Title XVIII of the Social Security Act, 1862 (a)(1)(a) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, 1862 (a)(14) defines other than physician services. Title XVIII of the Social Security Act, 1862 (a)(7) excludes routine physical examinations. Title XVIII of the Social Security Act, 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 42 CFR (a) indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). 42 CFR defines physician assistants' services. 42 CFR defines nurse practitioners' services. 42 CFR defines clinical nurse specialists' services. CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.2, , 80.3 & Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract: Fluorescein Fluorescein angiography is used in the diagnosis and treatment of a wide range of ocular disorders. Its visible fluorescence leaking from damaged vessels makes it particularly useful in the diagnosis of retinal vascular disorders and monitoring treatment of conditions amenable to laser photocoagulation. Printed on 1/29/2018. Page 2 of 24

3 The dye is injected intravenously and serial photographs are taken through the pupil. While morphological characteristics alone may be pathognomonic of certain disease states, the timing of appearance of the dye in the choroid, in the central retinal artery and in the filling (or otherwise) of the quadrants have diagnostic implications. Indocyanine Green Indocyanine green dye is injected intravenously into the patient to highlight the vessels in the retina and the deeper tissue layer of the choroid. Under infrared light, Indocyanine Green fluoresces allowing the choroidal vessels to be visualized through the retinal pigment epithelium or in the presence of retinal or vitreous hemorrhage that would otherwise obscure visualization. Indocyanine green angiography (ICG) is effective in the diagnosis and treatment of ill-defined choroidal neovascularization (e.g., associated with age related macular degeneration (AMD)). It is also useful in the evalution of feeder vessels, choroidal leakages in the late phase, and ruptures of the pigment epithelium. Indications: Fluorescein Fluorescein angiography with interpretation is medically necessary as an adjunct to the diagnosis of chorioretinal vascular abnormalities especially relating to choroid neovascularization, noninfective vasculitis, and age related macular degeneration. It may also be appropriate in evaluating intraocular tumors, visual loss in systemic disease, acute exudative inflammations such as toxoplasmosis and optic disc edema. Medical necessity for such angiography would generally be in the context of a changing clinical picture. Fluorescein angiography may be useful in diabetic retinopathy in identifying ischemia and neovascularization, locating microaneurysms, and defining macular edema. Fluorescein angiography following treatment, for example, of choroidal neovascularization (CNV) is necessary to monitor for recurrence or to detect additional treatable disease. Usually this is performed on the basis of a change in the clinical picture similar to the way it is employed prior to treatment. However, fluorescein angiography may be performed following treatment without clinical change in order to detect occult lesions. This will occur most often in CNV and very rarely in other diseases. Indocyanine Green Indocyanine green angiography (ICG) may be a valuable diagnostic adjunct to fluorescein angiography in the evaluation of the following conditions: Retinal neovascularization Choroid neovascularization Serous detachment of retinal pigment epithelium Hemorrhagic detachment of retinal pigment epithelium Retinal hemorrhage Limitations: Fluorescein Studies performed for screening will be denied by Medicare as not medically necessary. Fluorescein angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner. If excluded by State law, optometrists may not be reimbursed for fluorescein angiography. Fluorescein angiography of an asymptomatic contralateral without new abnormalities on ophthalmoscopic exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each. Indocyanine Green Indocyanine green angiography must be performed under the direct supervision (physician present in the office and immediately available) of a physician when done by a non-physician practitioner. Printed on 1/29/2018. Page 3 of 24

4 If excluded by State law, optometrists may not be reimbursed for ICG angiography. Indocyanine green is formulated with iodine and should not be used on patients who are allergic to iodine. ICG for the evaluation of patients with background diabetic retinopathy is not considered to be a medically necessary service. ICG angiography of an asymptomatic contralateral without new abnormalities on ophthalmoscopic exam, in patients with unilateral AMD or other disease, will be denied as not medically necessary. Evidence of medical necessity must be documented in the medical record for each. Studies performed for screening will be denied by Medicare as not medically necessary. Other Comments: Limitation of liability and refund requirements apply when denials are based on medical necessity. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For outpatient settings other than CORFs, references to "physicians" throughout this policy include nonphysicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Section CMS National Coverage Policy). Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A 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. N/A 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. Printed on 1/29/2018. Page 4 of 24

5 N/A CPT/HCPCS Codes Group 1 Paragraph: CPT Code can only be billed with a single diagnosis if that diagnosis is a covered diagnosis for both CPT Code and CPT Code If the diagnosis to be billed for CPT is only a covered diagnosis for one of the two procedures encompassed in CPT 92242, the provider also needs to include a second diagnosis code on the claim that is a covered diagnosis for the other of the two studies in order to indicate that there exists a covered diagnosis for both studies included in CPT Group 1 Codes: FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL FLUORESCEIN ANGIOGRAPHY AND INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) PERFORMED AT THE SAME PATIENT ENCOUNTER WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The correct use of an ICD-10 code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. ICD-10 Codes for Fluorescein Angiography (92235) Group 1 Codes: ICD-10 Codes A18.53 Tuberculous chorioretinitis B20 Human immunodeficiency virus [HIV] disease B39.4 Histoplasmosis capsulati, unspecified B39.5 Histoplasmosis duboisii B39.9 Histoplasmosis, unspecified B58.01 Toxoplasma chorioretinitis C69.20 Malignant neoplasm of unspecified retina C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.30 Malignant neoplasm of unspecified choroid C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid D18.09 Hemangioma of other sites D31.20 Benign neoplasm of unspecified retina D31.21 Benign neoplasm of right retina D31.22 Benign neoplasm of left retina D31.30 Benign neoplasm of unspecified choroid D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid D57.00 Hb-SS disease with crisis, unspecified D57.01 Hb-SS disease with acute chest syndrome D57.02 Hb-SS disease with splenic sequestration D57.1 Sickle-cell disease without crisis D57.20 Sickle-cell/Hb-C disease without crisis D Sickle-cell/Hb-C disease with acute chest syndrome D Sickle-cell/Hb-C disease with splenic sequestration D Sickle-cell/Hb-C disease with crisis, unspecified D57.80 Other sickle-cell disorders without crisis Printed on 1/29/2018. Page 5 of 24

6 ICD-10 Codes D Other sickle-cell disorders with acute chest syndrome D Other sickle-cell disorders with splenic sequestration D Other sickle-cell disorders with crisis, unspecified D86.0 Sarcoidosis of lung D86.1 Sarcoidosis of lymph nodes D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes D86.3 Sarcoidosis of skin D86.81 Sarcoid meningitis D86.82 Multiple cranial nerve palsies in sarcoidosis D86.83 Sarcoid iridocyclitis D86.84 Sarcoid pyelonephritis D86.85 Sarcoid myocarditis D86.86 Sarcoid arthropathy D86.87 Sarcoid myositis D86.89 Sarcoidosis of other sites D86.9 Sarcoidosis, unspecified E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right Printed on 1/29/2018. Page 6 of 24

7 ICD-10 Codes E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right Printed on 1/29/2018. Page 7 of 24

8 ICD-10 Codes E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Printed on 1/29/2018. Page 8 of 24

9 ICD-10 Codes Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E Printed on 1/29/2018. Page 9 of 24

10 ICD-10 Codes Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left Printed on 1/29/2018. Page 10 of 24

11 ICD-10 Codes E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right Printed on 1/29/2018. Page 11 of 24

12 ICD-10 Codes E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, E13.36 Other specified diabetes mellitus with diabetic cataract E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E78.00 Pure hypercholesterolemia, unspecified E78.01 Familial hypercholesterolemia E Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure E Postprocedural hematoma of an endocrine system organ or structure following other procedure E Postprocedural seroma of an endocrine system organ or structure following an endocrine system procedure E Postprocedural seroma of an endocrine system organ or structure following other procedure G35 Multiple sclerosis G45.3 Amaurosis fugax G93.2 Benign intracranial hypertension H Unspecified focal chorioretinal inflammation, right H Unspecified focal chorioretinal inflammation, left H Unspecified focal chorioretinal inflammation, H Focal chorioretinal inflammation, juxtapapillary, right H Focal chorioretinal inflammation, juxtapapillary, left H Focal chorioretinal inflammation, juxtapapillary, H Focal chorioretinal inflammation of posterior pole, right H Focal chorioretinal inflammation of posterior pole, left H Focal chorioretinal inflammation of posterior pole, H Focal chorioretinal inflammation, peripheral, right H Focal chorioretinal inflammation, peripheral, left H Focal chorioretinal inflammation, peripheral, H Focal chorioretinal inflammation, macular or paramacular, right H Focal chorioretinal inflammation, macular or paramacular, left H Focal chorioretinal inflammation, macular or paramacular, H Unspecified disseminated chorioretinal inflammation, right H Unspecified disseminated chorioretinal inflammation, left H Unspecified disseminated chorioretinal inflammation, H Disseminated chorioretinal inflammation of posterior pole, right H Disseminated chorioretinal inflammation of posterior pole, left H Disseminated chorioretinal inflammation of posterior pole, H Disseminated chorioretinal inflammation, peripheral right H Disseminated chorioretinal inflammation, peripheral, left H Disseminated chorioretinal inflammation, peripheral, H Disseminated chorioretinal inflammation, generalized, right H Disseminated chorioretinal inflammation, generalized, left H Disseminated chorioretinal inflammation, generalized, Printed on 1/29/2018. Page 12 of 24

13 ICD-10 Codes H Acute posterior multifocal placoid pigment epitheliopathy, right H Acute posterior multifocal placoid pigment epitheliopathy, left H Acute posterior multifocal placoid pigment epitheliopathy, H30.21 Posterior cyclitis, right H30.22 Posterior cyclitis, left H30.23 Posterior cyclitis, H Harada's disease, right H Harada's disease, left H Harada's disease, H Other chorioretinal inflammations, right H Other chorioretinal inflammations, left H Other chorioretinal inflammations, H30.91 Unspecified chorioretinal inflammation, right H30.92 Unspecified chorioretinal inflammation, left H30.93 Unspecified chorioretinal inflammation, H Solar retinopathy, right H Solar retinopathy, left H Solar retinopathy, H Choroidal degeneration, unspecified, right H Choroidal degeneration, unspecified, left H Choroidal degeneration, unspecified, H Age-related choroidal atrophy, right H Age-related choroidal atrophy, left H Age-related choroidal atrophy, H Diffuse secondary atrophy of choroid, right H Diffuse secondary atrophy of choroid, left H Diffuse secondary atrophy of choroid, H31.21 Choroideremia H31.29 Other hereditary choroidal dystrophy H Choroidal rupture, right H Choroidal rupture, left H Choroidal rupture, H Hemorrhagic choroidal detachment, right H Hemorrhagic choroidal detachment, left H Hemorrhagic choroidal detachment, H Serous choroidal detachment, right H Serous choroidal detachment, left H Serous choroidal detachment, H32 Chorioretinal disorders in diseases classified elsewhere H Unspecified retinoschisis, right H Unspecified retinoschisis, left H Unspecified retinoschisis, H Cyst of ora serrata, right H Cyst of ora serrata, left H Cyst of ora serrata, H Other retinoschisis and retinal cysts, right H Other retinoschisis and retinal cysts, left H Other retinoschisis and retinal cysts, H33.21 Serous retinal detachment, right H33.22 Serous retinal detachment, left H33.23 Serous retinal detachment, H34.01 Transient retinal artery occlusion, right H34.02 Transient retinal artery occlusion, left H34.03 Transient retinal artery occlusion, H34.11 Central retinal artery occlusion, right H34.12 Central retinal artery occlusion, left H34.13 Central retinal artery occlusion, H Retinal artery branch occlusion, right Printed on 1/29/2018. Page 13 of 24

14 ICD-10 Codes H Retinal artery branch occlusion, left H Retinal artery branch occlusion, H Central retinal vein occlusion, right, with macular edema H Central retinal vein occlusion, right, with retinal neovascularization H Central retinal vein occlusion, right, stable H Central retinal vein occlusion, left, with macular edema H Central retinal vein occlusion, left, with retinal neovascularization H Central retinal vein occlusion, left, stable H Central retinal vein occlusion,, with macular edema H Central retinal vein occlusion,, with retinal neovascularization H Central retinal vein occlusion,, stable H Venous engorgement, right H Venous engorgement, left H Venous engorgement, H Tributary (branch) retinal vein occlusion, right, with macular edema H Tributary (branch) retinal vein occlusion, right, with retinal neovascularization H Tributary (branch) retinal vein occlusion, right, stable H Tributary (branch) retinal vein occlusion, left, with macular edema H Tributary (branch) retinal vein occlusion, left, with retinal neovascularization H Tributary (branch) retinal vein occlusion, left, stable H Tributary (branch) retinal vein occlusion,, with macular edema H Tributary (branch) retinal vein occlusion,, with retinal neovascularization H Tributary (branch) retinal vein occlusion,, stable H34.9 Unspecified retinal vascular occlusion H Exudative retinopathy, right H Exudative retinopathy, left H Exudative retinopathy, H Hypertensive retinopathy, right H Hypertensive retinopathy, left H Hypertensive retinopathy, H Retinal micro-aneurysms, unspecified, right H Retinal micro-aneurysms, unspecified, left H Retinal micro-aneurysms, unspecified, H Retinal neovascularization, unspecified, right H Retinal neovascularization, unspecified, left H Retinal neovascularization, unspecified, H Retinal vasculitis, right H Retinal vasculitis, left H Retinal vasculitis, H Retinal telangiectasis, right H Retinal telangiectasis, left H Retinal telangiectasis, H35.09 Other intraretinal microvascular abnormalities H35.21 Other non-diabetic proliferative retinopathy, right H35.22 Other non-diabetic proliferative retinopathy, left H35.23 Other non-diabetic proliferative retinopathy, H Nonexudative age-related macular degeneration, right, early dry stage H Nonexudative age-related macular degeneration, right, intermediate dry stage H Nonexudative age-related macular degeneration, right, advanced atrophic without subfoveal involvement H Nonexudative age-related macular degeneration, right, advanced atrophic with subfoveal involvement H Nonexudative age-related macular degeneration, left, early dry stage H Nonexudative age-related macular degeneration, left, intermediate dry stage H Nonexudative age-related macular degeneration, left, advanced atrophic without subfoveal involvement H Nonexudative age-related macular degeneration, left, advanced atrophic with subfoveal involvement Printed on 1/29/2018. Page 14 of 24

15 ICD-10 Codes H Nonexudative age-related macular degeneration,, early dry stage H Nonexudative age-related macular degeneration,, intermediate dry stage H Nonexudative age-related macular degeneration,, advanced atrophic without subfoveal involvement H Nonexudative age-related macular degeneration,, advanced atrophic with subfoveal involvement H Exudative age-related macular degeneration, right, with active choroidal neovascularization H Exudative age-related macular degeneration, right, with inactive choroidal neovascularization H Exudative age-related macular degeneration, right, with inactive scar H Exudative age-related macular degeneration, left, with active choroidal neovascularization H Exudative age-related macular degeneration, left, with inactive choroidal neovascularization H Exudative age-related macular degeneration, left, with inactive scar H Exudative age-related macular degeneration,, with active choroidal neovascularization H Exudative age-related macular degeneration,, with inactive choroidal neovascularization H Exudative age-related macular degeneration,, with inactive scar H35.33 Angioid streaks of macula H Macular cyst, hole, or pseudohole, right H Macular cyst, hole, or pseudohole, left H Macular cyst, hole, or pseudohole, H Cystoid macular degeneration, right H Cystoid macular degeneration, left H Cystoid macular degeneration, H Drusen (degenerative) of macula, right H Drusen (degenerative) of macula, left H Drusen (degenerative) of macula, H Puckering of macula, right H Puckering of macula, left H Puckering of macula, H Toxic maculopathy, right H Toxic maculopathy, left H Toxic maculopathy, 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 H35.62 Retinal hemorrhage, left H35.63 Retinal hemorrhage, H Central serous chorioretinopathy, right H Central serous chorioretinopathy, left H Central serous chorioretinopathy, H Serous detachment of retinal pigment epithelium, right H Serous detachment of retinal pigment epithelium, left H Serous detachment of retinal pigment epithelium, H Hemorrhagic detachment of retinal pigment epithelium, right H Hemorrhagic detachment of retinal pigment epithelium, left H Hemorrhagic detachment of retinal pigment epithelium, H35.81 Retinal edema H35.82 Retinal ischemia H43.11 Vitreous hemorrhage, right H43.12 Vitreous hemorrhage, left H43.13 Vitreous hemorrhage, H Vitreomacular adhesion, right H Vitreomacular adhesion, left H Vitreomacular adhesion, H43.89 Other disorders of vitreous body H43.9 Unspecified disorder of vitreous body H44.21 Degenerative myopia, right H44.22 Degenerative myopia, left Printed on 1/29/2018. Page 15 of 24

16 ICD-10 Codes H44.23 Degenerative myopia, H44.2A1 Degenerative myopia with choroidal neovascularization, right H44.2A2 Degenerative myopia with choroidal neovascularization, left H44.2A3 Degenerative myopia with choroidal neovascularization, H44.2B1 Degenerative myopia with macular hole, right H44.2B2 Degenerative myopia with macular hole, left H44.2B3 Degenerative myopia with macular hole, H44.2E1 Degenerative myopia with other maculopathy, right H44.2E2 Degenerative myopia with other maculopathy, left H44.2E3 Degenerative myopia with other maculopathy, H46.01 Optic papillitis, right H46.02 Optic papillitis, left H46.03 Optic papillitis, H Ischemic optic neuropathy, right H Ischemic optic neuropathy, left H Ischemic optic neuropathy, H47.10 Unspecified papilledema H Drusen of optic disc, right H Drusen of optic disc, left H Drusen of optic disc, H Pseudopapilledema of optic disc, right H Pseudopapilledema of optic disc, left H Pseudopapilledema of optic disc, H Other disorders of optic disc, right H Other disorders of optic disc, left H Other disorders of optic disc, H Cystoid macular edema following cataract surgery, right H Cystoid macular edema following cataract surgery, left H Cystoid macular edema following cataract surgery, M06.9 Rheumatoid arthritis, unspecified Q14.8 Other congenital malformations of posterior segment of Z Other long term (current) drug therapy Group 2 Paragraph: ICD-10 Codes For Indocyanine Green Angiography (92240) Group 2 Codes: ICD-10 Codes A18.53 Tuberculous chorioretinitis D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid H Unspecified disseminated chorioretinal inflammation, right H Unspecified disseminated chorioretinal inflammation, left H Unspecified disseminated chorioretinal inflammation, H Disseminated chorioretinal inflammation of posterior pole, right H Disseminated chorioretinal inflammation of posterior pole, left H Disseminated chorioretinal inflammation of posterior pole, H Disseminated chorioretinal inflammation, peripheral right H Disseminated chorioretinal inflammation, peripheral, left H Disseminated chorioretinal inflammation, peripheral, H Disseminated chorioretinal inflammation, generalized, right H Disseminated chorioretinal inflammation, generalized, left H Disseminated chorioretinal inflammation, generalized, H31.8 Other specified disorders of choroid Printed on 1/29/2018. Page 16 of 24