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1 Local Coverage Determination (LCD): Visual Fields (L34615) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Printed on 10/4/2017. Page 1 of 42 Contract Type Contract Number Jurisdiction State(s) MAC - Part A MAC A J - 05 Iowa MAC - Part B MAC B J - 05 Iowa MAC - Part A MAC A J - 05 Kansas MAC - Part B MAC B J - 05 Kansas MAC - Part A MAC A J - 05 MAC - Part B MAC B J - 05 Missouri - Entire State Missouri - Entire State MAC - Part A MAC A J - 05 Nebraska MAC - Part B MAC B J - 05 Nebraska MAC - Part A MAC A J - 05 Alaska Alabama Arkansas Arizona Connecticut Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maine Michigan Minnesota Missouri - Entire State Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey Ohio Oregon Rhode Island South Carolina South Dakota Tennessee Utah

2 Contractor Name Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Wisconsin Physicians Service Insurance Corporation Back to Top Contract Type Contract Number Jurisdiction State(s) Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming MAC - Part A MAC A J - 08 Indiana MAC - Part B MAC B J - 08 Indiana MAC - Part A MAC A J - 08 Michigan MAC - Part B MAC B J - 08 Michigan LCD Information Document Information LCD ID L34615 Original ICD-9 LCD ID L31348 LCD Title Visual Fields Proposed LCD in Comment Period N/A Source Proposed LCD N/A 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. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2017 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 10/4/2017. Page 2 of 42

3 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, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary. CMS Pub , Medicare Benefit Policy Manual, Chapter 16 General Exclusions From Coverage, Section 90 Routine Services and Appliances. 42 CFR Section 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) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Visual fields are examined by the use of static or kinetic perimetry. The procedure is performed separately for each eye, and measures the combined function of the retina, the optic nerve, and the intracranial visual pathway. It is used clinically to detect or monitor field loss due to disease at any of these locations. Visual fields may be determined by several methods including a tangent screen, Goldmann perimeter, and computerized automated perimeters. Visual field examinations will be considered medically necessary under the following conditions: 1. Disorder of the eyelids potentially affecting the visual field. 2. A documented diagnosis of glaucoma. Stabilization or progression of glaucoma can be monitored by a visual field examination, or by such services as scanning computerized ophthalmic diagnostic imaging. This evaluation must be performed at regular intervals to determine that the prescribed management is adequately controlling progression of disease to the degree possible. The frequency of such examinations is dependent on clinical judgment as well as the variability of intraocular pressure measurements (i.e., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages and progressive cupping of the optic nerve. 3. A diagnosis of glaucoma is suspected with supporting evidence documented. A suspected diagnosis of glaucoma is evidenced by an increase in intraocular pressure over time, intraocular pressures of 22 mm Hg or more, asymmetric intraocular measurements of greater than 2 mm Hg between the two eyes, or has optic nerves suspicious for glaucoma, which may be manifested as asymmetrical cupping, a change in the cup-to-disc ratio over time, disc hemorrhage, or an absent, thinned or notched neural rim. Additional possible indicators of glaucoma suspicion are fallout of the retinal nerve fiber layer, optic atrophy (pallor of the optic nerve), corneal endothelial pigment deposits (Krukenburg's Spindle), dense pigmentation of the trabecular meshwork as evidenced by gonioscopy, pseudoexfoliation of the lens or dense exfoliative deposits on the trabecular meshwork as evidenced by gonioscopy. Printed on 10/4/2017. Page 3 of 42

4 4. A documented disorder of the optic nerve, the neurologic visual pathway, or retina. Patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients who are about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field would not be indicated. 5. A recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology. 6. A recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia or giant cell arteritis. 7. A history of a cerebral aneurysm, pituitary tumor, occipital tumor or other condition potentially affecting the visual fields. 8. A visual field defect demonstrated by gross visual field testing (e.g., confrontation testing). 9. An initial workup for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis. 10. A disorder of the orbit, potentially affecting the visual field (e.g. orbital tumor, thyroid disease, etc.). 11. A significant eye injury. 12. Unexplained visual loss which may be described as "trouble seeing or vision going in and out." 13. A pale or swollen optic nerve documented by a recent examination. 14. New functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things). 15. Medication treatment (e.g., hydroxychloroquine) which has a high risk of potentially affecting the visual system. 16. Initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70. Limitations Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological services and should not be reported separately. Frequency of examinations for a diagnosis of macular degeneration or an experienced central vision loss (or to evaluate the results of a surgical intervention or for the possible need for surgical intervention) is dictated by stage of disease or degree of risk factors, just as with glaucoma evaluation. Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A 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 Printed on 10/4/2017. Page 4 of 42

5 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 : 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 : VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT) VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR SEMIQUANTITATIVE, AUTOMATED SUPRATHRESHOLD SCREENING PROGRAM, HUMPHREY SUPRATHRESHOLD AUTOMATIC DIAGNOSTIC TEST, OCTOPUS PROGRAM 33) VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND STATIC DETERMINATION WITHIN THE CENTRAL 30 DEG, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G-1, 32 OR 42, HUMPHREY VISUAL FIELD ANALYZER FULL THRESHOLD PROGRAMS 30-2, 24-2, OR 30/60-2) ICD-10 that Support Medical Necessity Group 1 Paragraph: Note: ICD-10 codes must be coded to the highest level of specificity. Group 1 : ICD-10 A18.51 Tuberculous episcleritis A18.53 Tuberculous chorioretinitis A18.54 Tuberculous iridocyclitis A18.59 Other tuberculosis of eye A52.15 Late syphilitic neuropathy A52.2 Asymptomatic neurosyphilis A52.71 Late syphilitic oculopathy B58.01 Toxoplasma chorioretinitis C69.01 Malignant neoplasm of right conjunctiva C69.02 Malignant neoplasm of left conjunctiva C69.11 Malignant neoplasm of right cornea C69.12 Malignant neoplasm of left cornea C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid C69.41 Malignant neoplasm of right ciliary body Printed on 10/4/2017. Page 5 of 42

6 C69.42 Malignant neoplasm of left ciliary body C69.51 Malignant neoplasm of right lacrimal gland and duct C69.52 Malignant neoplasm of left lacrimal gland and duct C69.61 Malignant neoplasm of right orbit C69.62 Malignant neoplasm of left orbit C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa C69.91 Malignant neoplasm of unspecified site of right eye C69.92 Malignant neoplasm of unspecified site of left eye C70.0 Malignant neoplasm of cerebral meninges C70.1 Malignant neoplasm of spinal meninges C70.9 Malignant neoplasm of meninges, unspecified C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of occipital lobe C71.5 Malignant neoplasm of cerebral ventricle C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem C71.8 Malignant neoplasm of overlapping sites of brain C72.0 Malignant neoplasm of spinal cord C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve C72.31 Malignant neoplasm of right optic nerve C72.32 Malignant neoplasm of left optic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.59 Malignant neoplasm of other cranial nerves C75.1 Malignant neoplasm of pituitary gland C75.2 Malignant neoplasm of craniopharyngeal duct C79.31 Secondary malignant neoplasm of brain C79.32 Secondary malignant neoplasm of cerebral meninges C79.49 Secondary malignant neoplasm of other parts of nervous system D09.21 Carcinoma in situ of right eye D09.22 Carcinoma in situ of left eye D18.02 Hemangioma of intracranial structures D18.09 Hemangioma of other sites D31.01 Benign neoplasm of right conjunctiva D31.02 Benign neoplasm of left conjunctiva D31.11 Benign neoplasm of right cornea D31.12 Benign neoplasm of left cornea D31.21 Benign neoplasm of right retina D31.22 Benign neoplasm of left retina D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid D31.41 Benign neoplasm of right ciliary body D31.42 Benign neoplasm of left ciliary body D31.51 Benign neoplasm of right lacrimal gland and duct D31.52 Benign neoplasm of left lacrimal gland and duct D31.61 Benign neoplasm of unspecified site of right orbit D31.62 Benign neoplasm of unspecified site of left orbit D31.91 Benign neoplasm of unspecified part of right eye D31.92 Benign neoplasm of unspecified part of left eye D32.0 Benign neoplasm of cerebral meninges D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.3 Benign neoplasm of cranial nerves Printed on 10/4/2017. Page 6 of 42

7 D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D43.3 Neoplasm of uncertain behavior of cranial nerves D43.8 Neoplasm of uncertain behavior of other specified parts of central nervous system D44.3 Neoplasm of uncertain behavior of pituitary gland D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct D48.7 Neoplasm of uncertain behavior of other specified sites D49.81 Neoplasm of unspecified behavior of retina and 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 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 E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E Printed on 10/4/2017. Page 7 of 42

8 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Printed on 10/4/2017. Page 8 of 42

9 E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Printed on 10/4/2017. Page 9 of 42

10 E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Printed on 10/4/2017. Page 10 of 42

11 E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Printed on 10/4/2017. Page 11 of 42

12 E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral 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 eye E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Printed on 10/4/2017. Page 12 of 42

13 E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral E13.36 Other specified diabetes mellitus with diabetic cataract E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E50.0 Vitamin A deficiency with conjunctival xerosis E50.1 Vitamin A deficiency with Bitot's spot and conjunctival xerosis E50.2 Vitamin A deficiency with corneal xerosis E50.3 Vitamin A deficiency with corneal ulceration and xerosis E50.4 Vitamin A deficiency with keratomalacia E50.5 Vitamin A deficiency with night blindness E50.6 Vitamin A deficiency with xerophthalmic scars of cornea E50.7 Other ocular manifestations of vitamin A deficiency E64.1 Sequelae of vitamin A deficiency F44.6 Conversion disorder with sensory symptom or deficit F44.7 Conversion disorder with mixed symptom presentation G35 Multiple sclerosis G36.9 Acute disseminated demyelination, unspecified G37.9 Demyelinating disease of central nervous system, unspecified G Migraine without aura, not intractable, with status migrainosus G Migraine without aura, not intractable, without status migrainosus G Migraine without aura, intractable, with status migrainosus G Migraine without aura, intractable, without status migrainosus G Migraine with aura, not intractable, with status migrainosus G Migraine with aura, not intractable, without status migrainosus G Migraine with aura, intractable, with status migrainosus G Migraine with aura, intractable, without status migrainosus G Hemiplegic migraine, not intractable, with status migrainosus G Hemiplegic migraine, not intractable, without status migrainosus G Hemiplegic migraine, intractable, with status migrainosus G Hemiplegic migraine, intractable, without status migrainosus G Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus Printed on 10/4/2017. Page 13 of 42

14 G Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus G Persistent migraine aura without cerebral infarction, intractable, with status migrainosus G Persistent migraine aura without cerebral infarction, intractable, without status migrainosus G Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus G Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus G Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G Persistent migraine aura with cerebral infarction, intractable, without status migrainosus G Chronic migraine without aura, not intractable, with status migrainosus G Chronic migraine without aura, not intractable, without status migrainosus G Chronic migraine without aura, intractable, with status migrainosus G Chronic migraine without aura, intractable, without status migrainosus G43.A0 Cyclical vomiting, not intractable G43.A1 Cyclical vomiting, intractable G43.B0 Ophthalmoplegic migraine, not intractable G43.B1 Ophthalmoplegic migraine, intractable G43.C0 Periodic headache syndromes in child or adult, not intractable G43.C1 Periodic headache syndromes in child or adult, intractable G43.D0 Abdominal migraine, not intractable G43.D1 Abdominal migraine, intractable G Other migraine, not intractable, with status migrainosus G Other migraine, not intractable, without status migrainosus G Other migraine, intractable, with status migrainosus G Other migraine, intractable, without status migrainosus G Menstrual migraine, not intractable, with status migrainosus G Menstrual migraine, not intractable, without status migrainosus G Menstrual migraine, intractable, with status migrainosus G Menstrual migraine, intractable, without status migrainosus G Migraine, unspecified, not intractable, with status migrainosus G Migraine, unspecified, not intractable, without status migrainosus G Migraine, unspecified, intractable, with status migrainosus G Migraine, unspecified, intractable, without status migrainosus G45.0 Vertebro-basilar artery syndrome G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.3 Amaurosis fugax G45.8 Other transient cerebral ischemic attacks and related syndromes G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome G90.1 Familial dysautonomia [Riley-Day] G92 Toxic encephalopathy G93.2 Benign intracranial hypertension H02.31 Blepharochalasis right upper eyelid H02.32 Blepharochalasis right lower eyelid H02.34 Blepharochalasis left upper eyelid H02.35 Blepharochalasis left lower eyelid H Unspecified ptosis of right eyelid H Unspecified ptosis of left eyelid H Unspecified ptosis of bilateral eyelids H Mechanical ptosis of right eyelid H Mechanical ptosis of left eyelid H Mechanical ptosis of bilateral eyelids H Myogenic ptosis of right eyelid H Myogenic ptosis of left eyelid H Myogenic ptosis of bilateral eyelids H Paralytic ptosis of right eyelid H Paralytic ptosis of left eyelid H Paralytic ptosis of bilateral eyelids Printed on 10/4/2017. Page 14 of 42

15 H Dermatochalasis of right upper eyelid H Dermatochalasis of right lower eyelid H Dermatochalasis of left upper eyelid H Dermatochalasis of left lower eyelid H05.00 Unspecified acute inflammation of orbit H Cellulitis of right orbit H Cellulitis of left orbit H Cellulitis of bilateral orbits H Osteomyelitis of right orbit H Osteomyelitis of left orbit H Osteomyelitis of bilateral orbits H Periostitis of right orbit H Periostitis of left orbit H Periostitis of bilateral orbits H Tenonitis of right orbit H Tenonitis of left orbit H Tenonitis of bilateral orbits H05.10 Unspecified chronic inflammatory disorders of orbit H Granuloma of right orbit H Granuloma of left orbit H Granuloma of bilateral orbits H Orbital myositis, right orbit H Orbital myositis, left orbit H Orbital myositis, bilateral H05.20 Unspecified exophthalmos H Displacement (lateral) of globe, right eye H Displacement (lateral) of globe, left eye H Displacement (lateral) of globe, bilateral H Edema of right orbit H Edema of left orbit H Edema of bilateral orbit H Hemorrhage of right orbit H Hemorrhage of left orbit H Hemorrhage of bilateral orbit H Constant exophthalmos, right eye H Constant exophthalmos, left eye H Constant exophthalmos, bilateral H Intermittent exophthalmos, right eye H Intermittent exophthalmos, left eye H Intermittent exophthalmos, bilateral H Pulsating exophthalmos, right eye H Pulsating exophthalmos, left eye H Pulsating exophthalmos, bilateral H05.30 Unspecified deformity of orbit H Atrophy of right orbit H Atrophy of left orbit H Atrophy of bilateral orbit H Deformity of right orbit due to bone disease H Deformity of left orbit due to bone disease H Deformity of bilateral orbits due to bone disease H Deformity of right orbit due to trauma or surgery H Deformity of left orbit due to trauma or surgery H Deformity of bilateral orbits due to trauma or surgery H Enlargement of right orbit H Enlargement of left orbit H Enlargement of bilateral orbits H Exostosis of right orbit Printed on 10/4/2017. Page 15 of 42