Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34431)
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1 Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34431) 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 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 L34431 Previous Proposed LCD DL34431 Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/03/2016 LCD Title Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) AMA CPT / ADA CDT / AHA NUBC Copyright Statement 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. Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 08/18/2016 Notice Period End Date 10/02/2016 Printed on 10/3/2016. Page 1 of 23
2 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) excludes expenses incurred for items or services which are not 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, 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). CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.6 Intraocular Photography CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.9 Computer Enhanced Perimetry CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Laser Procedures Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract: Retinal thickness analysis is a non-invasive and non-contact imaging technique that takes direct cross-sectional images of the retina. These high resolution images capture ocular structures and provide data to create thickness maps of the retina. Retinal thickness is directly correlated to ocular disease, including retinal disorders and glaucoma. Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma is also diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range. Furthermore, most patients having abnormally high pressures will never suffer glaucomatous damage to their vision. Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) allows for early detection of glaucomatous damage to the nerve fiber layer or optic nerve of the. It is the goal of these diagnostic imaging tests to discriminate among patients with normal intraocular pressures (IOP) who have glaucoma, patients with elevated IOP who have glaucoma, and patients with elevated IOP who do not have glaucoma. These tests can also provide precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of follow-up exams than visual field and/or disc photos. This can allow earlier and more efficient treatment of the disease process. Retinal Disorders Retinal disorders are the most common causes of severe and permanent vision loss. SCODI is a valuable tool for the evaluation and treatment of patients with retinal disease; including glaucoma; however, it is particularly useful in macular abnormalities. SCODI is able to detail the microscopic anatomy of the retina and the vitreoretinal interface. SCODI is useful in measuring the effectiveness of therapy in determining the need for ongoing therapy, or the cessation of therapy. Many forms of scanning computerized ophthalmic diagnostic imaging tests currently exist (e.g., confocal laser scanning ophthalmoscopy [topography], scanning laser polarimetry, optical coherence tomography [OCT], and retinal thickness analysis). Although these techniques are different, their objective is the same. Medicare will consider scanning computerized ophthalmic diagnostic imaging (SCODI) medically reasonable and necessary in evaluating retinal disorders and glaucoma as documented in this local coverage determination (LCD). Printed on 10/3/2016. Page 2 of 23
3 Indications and Limitations: Glaucoma Glaucoma commonly causes a spectrum of related and vision changes. These changes include an erosion of the optic nerve and associated retinal nerve fibers, as well as a loss of peripheral vision. A diagnosis of glaucoma is seldom made on the basis of a single clinical observation. The diagnosis relies upon the analysis of an assemblage of clinical data. The data includes evaluations of the optic nerve, retinal nerve fiber, anterior chamber structure, pigment in the anterior chamber, hemorrhages of the optic nerve, and particularly, loss of visual field. Clinical evaluation utilizing all available clinical data allows for early treatment and potential prevention of endstage therapies. SCODI allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. This technology can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure. SCODI may differentiate patients with elevated intraocular pressure and early glaucoma damage, from those without glaucoma. This allows for early treatment of the disease, preventing unnecessary medical or surgical therapy. The following codes would generally not be necessary with SCODI. When needed the same day, documentation must justify the procedures Fundus photography with interpretation and report Ophthalmoscopy, extended with retinal drawing (e.g., for retinal detachment, melanoma) with interpretation and report; initial Subsequent ophthalmoscopy B-scan (with or without superimposed non-quantitative A-scan) The physician is not precluded from performing one of the above listed procedures on the same day, if a procedure is necessary to evaluate the patient. The reason for performing one of the above procedures, in addition to SCODI, must be clearly documented in the medical record. SCODI is not considered reasonable and necessary when performed to provide confirmatory information regarding a diagnosis or treatment that has previously been determined. Glaucoma may be diagnosed as mild, moderate, or severe and SCODI can be utilized as documented below: Glaucoma Suspect or Mild Damage SCODI can be used to follow pre-glaucoma patients or those with mild damage and who would demonstrate any or all of the following: Visual Field no detectable visual field (VF) defect; "mild" generalized reduction in retinal sensitivity; "mild" constriction of isopters; nasal step peripheral to 20 degrees; and/or small relative defects of the Bjerrum area, peripheral to 9 degrees. Optic Nerve symmetric or vertically elongated cup enlargement; neural rim intact, rim: disc ratio > 0.2; cup:disc ratio <0.8; focal notch; rim:disc ratio > 0.2; cup:disc ratio <0.8 no definite pathologic cupping; and/or previously observed disc hemorrhage. Moderate Glaucomatous Damage In patients with moderate glaucomatous damage, alternating the use of SCODI and visual field tests within appropriate time intervals will be considered reasonable and necessary. Performance of SCODI and visual field tests on the same day, or separated by a short period of time (within three [3] months) is usually not considered reasonable and necessary.. However, there may be instances in which each test is needed to determine the Printed on 10/3/2016. Page 3 of 23
4 patient's status and treatment. The contractor expects that use of both tests on the same day or within short intervals will be the exception rather than the rule. Examples in which each test could be medically necessary include situations in which the clinical examination suggests progression of the glaucoma, yet the visual fields do not show new deficits. SCODI could be used to determine whether there is a change in the nerve fiber loss. Similarly, if the clinical examination showed progression and SCODI was unchanged, the visual field testing might be medically necessary to ascertain whether there is a functional loss of vision. If each test is performed on the same day or within short intervals, the rationale for medical necessity must be present in the medical record. Patients with moderate glaucomatous damage would be expected to demonstrate any or all of the following: Visual Field "moderate" generalized reduction in retinal sensitivity; "moderate" constriction of isopters absolute defects to within 9 degrees of fixation; and/or temporal wedge. Optic Nerve enlarged optic nerve cup with neural rim remaining but sloped or pale; focal notches with rim:disc ratio > 0.1 but <0.2; cup:disc ratio > 0.8 but <0.9; and/or prominent lamina cribrosa. Advanced Glaucomatous Damage SCODI is not considered reasonable and necessary for patients with advanced glaucomatous damage. Visual field testing should be performed since visual fields are more likely to detect small changes than scanning computerized ophthalmic diagnostic imaging. Patients with advanced glaucomatous damage would be expected to demonstrate any or all of the following: Visual Field "severe" generalized reduction in retinal sensitivity; "severe" constriction of isopters (i.e., 14e <10 degrees); absolute defects to within 3 degrees of fixation; loss of central acuity; and/or temporal island remains. Optic Nerve diffuse enlargement of optic nerve cup; rim:disc ratio <0.1; cup:disc ratio > 0.9; and/or wipe out of all or a portion of the neuroretinal rim. Compared to SCODI, scanning laser polarimetry is not an appropriate diagnostic technique for the management of retinal disorders. Back to Top Coding Information Bill Type : 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. Printed on 10/3/2016. Page 4 of 23
5 N/A Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue. N/A CPT/HCPCS Group 1 Paragraph: N/A Group 1 : SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA ICD-10 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. Group 1 : ICD-10 A18.53 Tuberculous chorioretinitis B39.4 Histoplasmosis capsulati, unspecified B39.5 Histoplasmosis duboisii B39.9 Histoplasmosis, unspecified C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema 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 Printed on 10/3/2016. Page 5 of 23
6 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 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 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, E08.37X1 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, E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema Printed on 10/3/2016. Page 6 of 23
7 E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema 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 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 Printed on 10/3/2016. Page 7 of 23
8 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, E09.37X1 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, E Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema 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 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 Printed on 10/3/2016. Page 8 of 23
9 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, 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, E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E 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 Printed on 10/3/2016. Page 9 of 23
10 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 E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, 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, E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema 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, Printed on 10/3/2016. Page 10 of 23
11 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 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, E13.37X1 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, G45.3 Amaurosis fugax H Secondary noninfectious iridocyclitis, right H Secondary noninfectious iridocyclitis, left H Secondary noninfectious iridocyclitis, H Degeneration of iris (pigmentary), right H Degeneration of iris (pigmentary), left H Degeneration of iris (pigmentary), H21.41 Pupillary membranes, right H21.42 Pupillary membranes, left H21.43 Pupillary membranes, H Goniosynechiae, right Printed on 10/3/2016. Page 11 of 23
12 H Goniosynechiae, left H Goniosynechiae, H Recession of chamber angle, right H Recession of chamber angle, left H Recession of chamber angle, 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, 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 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, H Unspecified choroidal detachment, right H Unspecified choroidal detachment, left Printed on 10/3/2016. Page 12 of 23
13 H Unspecified choroidal detachment, 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 retinal detachment with retinal break, right H Unspecified retinal detachment with retinal break, left H Unspecified retinal detachment with retinal break, H Retinal detachment with single break, right H Retinal detachment with single break, left H Retinal detachment with single break, H Retinal detachment with multiple breaks, right H Retinal detachment with multiple breaks, left H Retinal detachment with multiple breaks, H Retinal detachment with giant retinal tear, right H Retinal detachment with giant retinal tear, left H Retinal detachment with giant retinal tear, H Total retinal detachment, right H Total retinal detachment, left H Total retinal detachment, 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, H Unspecified retinal break, right H Unspecified retinal break, left H Unspecified retinal break, H Horseshoe tear of retina without detachment, right H Horseshoe tear of retina without detachment, left H Horseshoe tear of retina without detachment, H Round hole, right H Round hole, left H Round hole, H Multiple defects of retina without detachment, right H Multiple defects of retina without detachment, left H Multiple defects of retina without detachment, H33.41 Traction detachment of retina, right H33.42 Traction detachment of retina, left H33.43 Traction detachment of retina, H33.8 Other retinal detachments 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, Printed on 10/3/2016. Page 13 of 23
14 H Retinal artery branch occlusion, right 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 H Changes in retinal vascular appearance, right H Changes in retinal vascular appearance, left H Changes in retinal vascular appearance, 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 H Retrolental fibroplasia, right H Retrolental fibroplasia, left H Retrolental fibroplasia, 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, stage unspecified 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 Printed on 10/3/2016. Page 14 of 23
15 Nonexudative age-related macular degeneration, right, advanced atrophic with subfoveal involvement H Nonexudative age-related macular degeneration, left, stage unspecified 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 H Nonexudative age-related macular degeneration,, stage unspecified 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, stage unspecified 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, stage unspecified 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,, stage unspecified 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 Puckering of macula, right H Puckering of macula, left H Puckering of macula, H Toxic maculopathy, right H Toxic maculopathy, left H Toxic maculopathy, H Secondary vitreoretinal degeneration, right H Secondary vitreoretinal degeneration, left H Secondary vitreoretinal degeneration, 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 H35.62 Retinal hemorrhage, left H35.63 Retinal hemorrhage, H35.70 Unspecified separation of retinal layers 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 Printed on 10/3/2016. Page 15 of 23
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