Envolve Vision Policy

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1 Medical Policy Name Medical Policy Number Cataract Extraction Second Eye OC.UM.CP.0009 Envolve Vision Policy Policy Last Revised Date 1st review Coder/BA & date: icrm ICD-10 Code 12/11/2015 Approved date: Medical Policy ICD-9 Code ICD-9 Code Description ICD-10 Code Description Diabetic E08.36 Diabetes mellitus due to underlying condition with diabetic Diabetic E09.36 Drug or chemical induced diabetes mellitus with diabetic Diabetic E10.36 Type 1 diabetes mellitus with diabetic Diabetic E11.36 Type 2 diabetes mellitus with diabetic Diabetic E13.36 Other specified diabetes mellitus with diabetic Cortical senile H Cortical age-related, right eye Cortical senile H Cortical age-related, left eye Cortical senile H Cortical age-related, bilateral Anterior subcapsular polar senile H Anterior subcapsular polar age-related, right eye Anterior subcapsular polar senile H Anterior subcapsular polar age-related, left eye Anterior subcapsular polar senile H Anterior subcapsular polar age-related, bilateral Posterior subcapsular polar senile H Posterior subcapsular polar age-related, right eye Posterior subcapsular polar senile H Posterior subcapsular polar age-related, left eye Posterior subcapsular polar senile H Posterior subcapsular polar age-related, bilateral Incipient H Other age-related incipient, right eye Incipient H Other age-related incipient, left eye Incipient H Other age-related incipient, bilateral Nuclear sclerosis H25.11 Age-related nuclear, right eye BKH Review Date: Coder Comments

2 Nuclear sclerosis H25.12 Age-related nuclear, left eye Nuclear sclerosis H25.13 Age-related nuclear, bilateral Hypermature senile H25.21 Age-related, morgagnian type, right eye Hypermature senile H25.22 Age-related, morgagnian type, left eye Hypermature senile H25.23 Age-related, morgagnian type, bilateral Other and combined forms of senile H Combined forms of age-related, right eye Other and combined forms of senile H Combined forms of age-related, left eye Other and combined forms of senile H Combined forms of age-related, bilateral Pseudoexfoliation of lens capsule H25.89 Other age-related Total or mature senile H25.89 Other age-related Other and combined forms of senile H25.89 Other age-related Unspecified senile H25.9 Unspecified age-related Unspecified H Unspecified infantile and juvenile, right eye Unspecified H Unspecified infantile and juvenile, left eye Unspecified H Unspecified infantile and juvenile, bilateral Cortical, lamellar, or zonular, H Infantile and juvenile cortical, lamellar, or zonular, right eye Cortical, lamellar, or zonular, H Infantile and juvenile cortical, lamellar, or zonular, left eye Cortical, lamellar, or zonular, H Infantile and juvenile cortical, lamellar, or zonular, bilateral Nuclear, H Infantile and juvenile nuclear, right eye Nuclear, H Infantile and juvenile nuclear, left eye Nuclear, H Infantile and juvenile nuclear, bilateral Anterior subcapsular polar, Anterior subcapsular polar, H Anterior subcapsular polar infantile and juvenile, right eye H Anterior subcapsular polar infantile and juvenile, left eye

3 Anterior subcapsular polar, H Anterior subcapsular polar infantile and juvenile, bilateral Posterior subcapsular polar, H Posterior subcapsular polar infantile and juvenile, right eye Posterior subcapsular polar, H Posterior subcapsular polar infantile and juvenile, left eye Posterior subcapsular polar, H Posterior subcapsular polar infantile and juvenile, bilateral Other and combined forms of H Combined forms of infantile and juvenile, right eye Other and combined forms of H Combined forms of infantile and juvenile, left eye Other and combined forms of H Combined forms of infantile and juvenile, bilateral Other and combined forms of H26.09 Other infantile and juvenile Unspecified traumatic H Unspecified traumatic, right eye Unspecified traumatic H Unspecified traumatic, left eye Unspecified traumatic H Unspecified traumatic, bilateral Localized traumatic opacities of H Localized traumatic opacities, right eye Localized traumatic opacities of H Localized traumatic opacities, left eye Localized traumatic opacities of H Localized traumatic opacities, bilateral Partially resolved traumatic H Partially resolved traumatic, right eye Partially resolved traumatic H Partially resolved traumatic, left eye Partially resolved traumatic H Partially resolved traumatic, bilateral Total traumatic H Total traumatic, right eye Total traumatic H Total traumatic, left eye Total traumatic H Total traumatic, bilateral Unspecified a complicata H26.20 Unspecified complicated Cataract with ocular neovascularization H Cataract with neovascularization, right eye Cataract with ocular neovascularization H Cataract with neovascularization, left eye

4 Cataract with ocular neovascularization H Cataract with neovascularization, bilateral Cataract in inflammatory ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye Cataract in degenerative ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye Cataract in inflammatory ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), left eye Cataract in degenerative ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), left eye Cataract in inflammatory ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral Cataract in degenerative ocular disorders H Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral Cataract secondary to glaucomatous flecks H Glaucomatous flecks (subcapsular), right eye (subcapsular) Cataract secondary to glaucomatous flecks H Glaucomatous flecks (subcapsular), left eye (subcapsular) Cataract secondary to glaucomatous flecks H Glaucomatous flecks (subcapsular), bilateral (subcapsular) Toxic H26.31 Drug-induced, right eye Toxic H26.32 Drug-induced, left eye Toxic H26.33 Drug-induced, bilateral Unspecified after- H26.40 Unspecified secondary Soemmering's ring H Soemmering's ring, right eye Soemmering's ring H Soemmering's ring, left eye Soemmering's ring H Soemmering's ring, bilateral Other after-, not obscuring vision H Other secondary, right eye After-, obscuring vision H Other secondary, right eye Other after-, not obscuring vision H Other secondary, left eye After-, obscuring vision H Other secondary, left eye Other after-, not obscuring vision H Other secondary, bilateral After-, obscuring vision H Other secondary, bilateral

5 Cataract associated with radiation and H26.8 Other specified other physical influences Other H26.8 Other specified Unspecified H26.9 Unspecified Tetanic H28 Cataract in diseases classified elsewhere Myotonic H28 Cataract in diseases classified elsewhere Cataract associated with other syndromes H28 Cataract in diseases classified elsewhere

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