Local Coverage Determination (LCD): Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34431)

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 MAC 10111 - MAC A J - J Alabama Palmetto GBA A and B MAC 10211 - MAC A J - J Georgia Palmetto GBA A and B MAC 10311 - MAC A J - J Tennessee Palmetto GBA A and B and HHH MAC 11201 - MAC A J - M South Carolina Palmetto GBA A and B and HHH MAC 11202 - MAC B J - M South Carolina Palmetto GBA A and B and HHH MAC 11301 - MAC A J - M Virginia Palmetto GBA A and B and HHH MAC 11302 - MAC B J - M Virginia Palmetto GBA A and B and HHH MAC 11401 - MAC A J - M West Virginia Palmetto GBA A and B and HHH MAC 11402 - MAC B J - M West Virginia Palmetto GBA A and B and HHH MAC 11501 - MAC A J - M North Carolina Palmetto GBA A and B and HHH MAC 11502 - MAC B J - M North Carolina Back to Top LCD Information Document Information LCD ID L34431 Original ICD-9 LCD ID L31562 Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/29/2018 LCD Title Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) Proposed LCD in Comment Period N/A Source Proposed LCD DL34431 AMA CPT / ADA CDT / AHA NUBC Copyright Statement Revision Ending Date 02/25/2018 Retirement Date N/A Notice Period Start Date 05/11/2017 Notice Period End Date 06/25/2017 Printed on 1/29/2018. Page 1 of 31

CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A) 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 410.32(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 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.6 Intraocular Photography CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.9 Computer Enhanced Perimetry CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 140.5 Laser Procedures Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Background: Scanning computerized ophthalmic diagnostic imaging (SCODI) is a noninvasive, noncontact imaging technique that produces high resolution images of ocular structures. These high resolution images are used to provide qualitative and quantitative data about the structural or physiologic properties of structures in the anterior and posterior segment that have been validated as clinically useful in monitoring progression, resolution, or response to treatment of various ocular conditions involving the retina and optic nerve over time. Scanning computerized ophthalmic diagnostic imaging makes use of three distinct technologies to generate quantitative data: Printed on 1/29/2018. Page 2 of 31

confocal laser scanning ophthalmoscopy (CSLO) scanning laser polarimetry (SLO) optical coherence tomography (OCT) Examples of CSLO and SLO devices currently in use in clinical practice include the Heidelberg Laser Tomographic Scanner, Heidelberg Retinal Tomography (HRT), the GDx Nerve Fiber Analysis System, and the Retinal Thickness Analyzer (RTA). OCT is available from a number of manufacturers using one of two basic platforms, time domain (TD-OCT), such as the Visante anterior segment OCT, and the more widely used spectral, or Fourier, domain (SD/FD-OCT) such as the Spectralis, RTVue, Cirrus, and ivue. 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 disorders of the anterior and posterior segment as documented in this local coverage determination (LCD). Posterior Segment Glaucoma is the second leading cause of blindness worldwide, and a disease for which effective treatment to slow or prevent progressive vision loss is available. However, glaucoma is diagnostically challenging and the majority of patients are asymptomatic early in the course of disease when the disease is most amenable to treatment. At the time of diagnosis, approximately 10-39% of patients have irrecoverable vision loss from advanced glaucoma. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 40% of cases have pressures in the normal range while many other patients with abnormally high pressures do not suffer glaucomatous damage. Structural changes in the optic disc may not appear until a significant functional deficit (visual field loss) has occurred. There is no single diagnostic test that can be used exclusively to diagnose and monitor glaucoma. Diagnosis of glaucoma is made using an assemblage of data from tests that provide complementary assessments of the functional and structural status of the optic nerve. This often includes a comprehensive history and eye exam including visual acuity measurement, pupillary examination, intraocular pressure measurement, gonioscopy, anterior segment exam, fundoscopy, optic disc and retinal nerve fiber layer examination; and often confirmatory diagnostic tests including central corneal thickness measurement, visual field evaluation (preferably using automated perimetry), and quantitative imaging of the optic nerve head and retinal nerve fiber layer with stereoscopic disc photographs and scanning computerized ophthalmic diagnostic imaging. SCODI allows for early detection of glaucomatous damage to the retinal nerve fiber layer or optic disc and has demonstrated clinically utility in facilitating earlier diagnosis and treatment as well as monitoring for progression and response to treatment. SCODI also allows for differentiation and diagnosis of other disorders of the optic nerve as well as monitoring for progressive optic neuropathy and response to treatment in a number of neuro-ophthalmologic conditions. Retinal disorders are among the most common causes of severe and permanent vision loss. Scanning computerized ophthalmic diagnostic imaging (SCODI) is an invaluable tool for the evaluation and treatment of patients with retinal disease, particularly when there is macular involvement. SCODI is able to detail the microscopic anatomy of the retina, subretina, and vitreoretinal interface and provide information that has demonstrated evidence of superiority to other available techniques in a number of clinical studies. SCODI has demonstrated clinical utility in monitoring patients with retinal diseases for progression which is critical for judging a response to or need for treatment of a number of retinal conditions. SCODI has been validated for use in ongoing screening for drug-related ocular toxicity due to its ability to detect early photoreceptor damage in patients taking certain high-risk drugs. The use of SCODI should be performed according to the most current recommended guidelines. The current recommendations for monitoring patients taking chloroquine or hydroxychloroquine include 1) a baseline exam within the first year of commencement which should include a SD-OCT if any macular abnormalities are present, and, 2) annual screening beginning at the 5th year of exposure in patients who are on a dose Anterior Segment There are numerous reports in the literature detailing the potential applications of anterior segment optical coherence tomography (AS-OCT and SD-OCT with anterior segment imaging capabilities) to image and provide measurements of anterior segment structures in a number of clinical situations. The current literature consists primarily of qualitative and quantitative imaging and detection capabilities, though there remains a lack of consensus on the sensitivity, specificity, and predictive value of anterior segment OCT in the vast majority of anterior segment applications and no endorsement of its use over gonioscopy or ultrasound biomicroscopy. The strongest evidence in support of the clinical utility of anterior segment OCT lies in its ability to image the structures of the anterior chamber angle, particularly in narrow angles. Current recommended practice patterns Printed on 1/29/2018. Page 3 of 31

by the American Academy of Ophthalmology endorse gonioscopy as the preferred means of performing evaluation of the anterior chamber angle. Although there remains insufficient evidence to endorse anterior segment OCT as a substitute for gonioscopy, anterior segment OCT is a recommended option in cases where angle closure is suspected and the angle anatomy is not conducive to gonioscopic assessment. Indications and Limitations: SCODI Anterior Segment 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral. Anterior segment OCT is considered reasonable and necessary when ordered for the evaluation of narrow angle, suspected narrow angle, and mixed mechanism glaucoma: In patients who are unable to undergo gonioscopy due to cognitive or physical limitations. When anatomic features, corneal opacity, or corneal edema preclude gonioscopic visualization. Indications other than those stipulated in this LCD are considered investigational and are not covered. SCODI is not covered for screening. SCODI is not covered in the absence of an indication. It is expected that no more than two (2) anterior segment OCT tests per year would be indicated in evaluating patients with a diagnosis of angle closure suspect, narrow angles, angle closure, and mixed mechanism glaucoma without a significant change in clinical status. It is expected that no more than 1 (1) AS-OCT test per three (3) years would be indicated in evaluating patients with all forms of open angle glaucoma including glaucoma suspect, ocular hypertension, secondary glaucoma, and congenital glaucoma. SCODI Optic Nerve 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. SCODI of the optic disc (92133) is considered reasonable and necessary when ordered to: Aid in the early diagnosis of glaucoma and monitor for progression and response to treatment. Monitor glaucoma suspect patients for evidence of glaucomatous change. Detect further loss of optic nerve or retinal nerve fiber layer tissue to aid in monitoring for progression in advanced optic nerve damage and advanced visual field loss. Differentiate when there is a discrepancy between the clinical appearance of the optic nerve and the visual field. Provide additional information to facilitate diagnosis and management when visual field results are insufficient or cannot be performed due to visual, mental, physical, or age limitations of the patient. Differentiate causes of other optic nerve disorders when a diagnosis is in doubt. Aid in the diagnosis and management of other optic nerve disorders and neuro-ophthalmologic diseases involving changes in the optic nerve head and retinal nerve fiber layer. SCODI is not covered when used for screening. SCODI is not covered in the absence of an indication. SCODI (92133, 92134) and fundus photography (92250) are mutually exclusive codes. However, there may be a limited number of clinical situations in which it is necessary to perform both techniques in order to evaluate and treat the patient. In these situations, both CPT codes may be reported appending modifier 59 to indicate a distinct procedural service. Documentation supportive of the need to perform both techniques should be clear in the medical record. Printed on 1/29/2018. Page 4 of 31

It is expected that no more than one (1) SCODI test per year would be indicated in monitoring patients with glaucoma suspect without a significant change in clinical status. It is expected that no more than two (2) SCODI tests per year would be indicated in monitoring patients with progressive optic neuropathies, including glaucoma (mild, moderate, severe, and indeterminate) without a significant change in clinical status. Advancements in scanning computerized ophthalmic diagnostic imaging technologies have increased the utility of these devices in both the diagnosis of glaucoma and detection of glaucomatous progression. Hardware and software limitations can impact the reliability of these tests in more advanced cases of glaucoma particularly once the floor effect is reached whereby the ability to discern and measure thickness of the remaining neural tissue limits the ability to detect progression. The use of SCODI in advanced glaucoma is covered provided the hardware and software utilized continues to provide clinically meaningful measurements that allow for the detection of progression. SCODI Retina 92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina. SCODI of the retina (92134) is considered reasonable and necessary when ordered to: Aid in the diagnosis and management of retinal conditions which involve changes in the subretinal, intraretinal, and vitreoretinal relationships. Monitor for progression or resolution of conditions in order to determine the need for or response to treatment. Monitor for evidence of ocular toxicity in patients taking high risk drugs with a known potential for causing toxic retinopathy. SCODI is not covered when used for screening. SCODI is not covered in the absence of an indication. SCODI should only be performed at clinically reasonable intervals (i.e., consistent with a noted change in clinical status or after sufficient time has elapsed to assess for progression or response to treatment). It is generally expected that conditions requiring more aggressive treatment and monitoring due to changing clinical status or treatment interventions will generally not require SCODI testing more than one (1) per month. Current recommendations for monitoring patients taking chloroquine or hydroxychloroquine who are on a dose Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A Back to Top Coding Information Bill Type Codes: Printed on 1/29/2018. Page 5 of 31

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. N/A Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH 92132 INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH 92133 INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH 92134 INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: 92132 The use of one code from both Group 1 and Group 2 should be selected when billing for 92132. In the event the coding does not adequately describe the specific patient circumstances precluding gonioscopic assessment of the anterior chamber angle which necessitate anterior segment OCT, supporting documentation should be clearly documented in the medical record. Group 1 Codes: ICD-10 Codes A18.59 Other tuberculosis of eye H17.01 Adherent leukoma, right eye H17.02 Adherent leukoma, left eye H17.03 Adherent leukoma, bilateral H17.11 Central corneal opacity, right eye H17.12 Central corneal opacity, left eye H17.13 Central corneal opacity, bilateral H17.811 Minor opacity of cornea, right eye H17.812 Minor opacity of cornea, left eye H17.813 Minor opacity of cornea, bilateral H17.821 Peripheral opacity of cornea, right eye H17.822 Peripheral opacity of cornea, left eye H17.823 Peripheral opacity of cornea, bilateral H17.89 Other corneal scars and opacities H17.9 Unspecified corneal scar and opacity H18.11 Bullous keratopathy, right eye H18.12 Bullous keratopathy, left eye H18.13 Bullous keratopathy, bilateral H18.20 Unspecified corneal edema H18.211 Corneal edema secondary to contact lens, right eye H18.212 Corneal edema secondary to contact lens, left eye H18.213 Corneal edema secondary to contact lens, bilateral H18.221 Idiopathic corneal edema, right eye Printed on 1/29/2018. Page 6 of 31

ICD-10 Codes H18.222 Idiopathic corneal edema, left eye H18.223 Idiopathic corneal edema, bilateral H21.82 Plateau iris syndrome (post-iridectomy) (postprocedural) Q13.1 Absence of iris Group 2 Paragraph: 92132 The use of one code from both Group 1 and Group 2 should be selected when billing for 92132. In the event the coding does not adequately describe the specific patient circumstances precluding gonioscopic assessment of the anterior chamber angle which necessitate anterior segment OCT, supporting documentation should be clearly documented in the medical record. Group 2 Codes: ICD-10 Codes H18.231 Secondary corneal edema, right eye H18.232 Secondary corneal edema, left eye H18.233 Secondary corneal edema, bilateral H21.231 Degeneration of iris (pigmentary), right eye H21.232 Degeneration of iris (pigmentary), left eye H21.233 Degeneration of iris (pigmentary), bilateral H21.41 Pupillary membranes, right eye H21.42 Pupillary membranes, left eye H21.43 Pupillary membranes, bilateral H21.521 Goniosynechiae, right eye H21.522 Goniosynechiae, left eye H21.523 Goniosynechiae, bilateral H21.551 Recession of chamber angle, right eye H21.552 Recession of chamber angle, left eye H21.553 Recession of chamber angle, bilateral H40.001 Preglaucoma, unspecified, right eye H40.002 Preglaucoma, unspecified, left eye H40.003 Preglaucoma, unspecified, bilateral H40.011 Open angle with borderline findings, low risk, right eye H40.012 Open angle with borderline findings, low risk, left eye H40.013 Open angle with borderline findings, low risk, bilateral H40.021 Open angle with borderline findings, high risk, right eye H40.022 Open angle with borderline findings, high risk, left eye H40.023 Open angle with borderline findings, high risk, bilateral H40.031 Anatomical narrow angle, right eye H40.032 Anatomical narrow angle, left eye H40.033 Anatomical narrow angle, bilateral H40.041 Steroid responder, right eye H40.042 Steroid responder, left eye H40.043 Steroid responder, bilateral H40.051 Ocular hypertension, right eye H40.052 Ocular hypertension, left eye H40.053 Ocular hypertension, bilateral H40.061 Primary angle closure without glaucoma damage, right eye H40.062 Primary angle closure without glaucoma damage, left eye H40.063 Primary angle closure without glaucoma damage, bilateral H40.10X1 Unspecified open-angle glaucoma, mild stage H40.10X2 Unspecified open-angle glaucoma, moderate stage H40.10X3 Unspecified open-angle glaucoma, severe stage H40.10X4 Unspecified open-angle glaucoma, indeterminate stage H40.1110 Primary open-angle glaucoma, right eye, stage unspecified H40.1111 Primary open-angle glaucoma, right eye, mild stage Printed on 1/29/2018. Page 7 of 31

ICD-10 Codes H40.1112 Primary open-angle glaucoma, right eye, moderate stage H40.1113 Primary open-angle glaucoma, right eye, severe stage H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage H40.1120 Primary open-angle glaucoma, left eye, stage unspecified H40.1121 Primary open-angle glaucoma, left eye, mild stage H40.1122 Primary open-angle glaucoma, left eye, moderate stage H40.1123 Primary open-angle glaucoma, left eye, severe stage H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified H40.1131 Primary open-angle glaucoma, bilateral, mild stage H40.1132 Primary open-angle glaucoma, bilateral, moderate stage H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage H40.1211 Low-tension glaucoma, right eye, mild stage H40.1212 Low-tension glaucoma, right eye, moderate stage H40.1213 Low-tension glaucoma, right eye, severe stage H40.1214 Low-tension glaucoma, right eye, indeterminate stage H40.1221 Low-tension glaucoma, left eye, mild stage H40.1222 Low-tension glaucoma, left eye, moderate stage H40.1223 Low-tension glaucoma, left eye, severe stage H40.1224 Low-tension glaucoma, left eye, indeterminate stage H40.1231 Low-tension glaucoma, bilateral, mild stage H40.1232 Low-tension glaucoma, bilateral, moderate stage H40.1233 Low-tension glaucoma, bilateral, severe stage H40.1234 Low-tension glaucoma, bilateral, indeterminate stage H40.1311 Pigmentary glaucoma, right eye, mild stage H40.1312 Pigmentary glaucoma, right eye, moderate stage H40.1313 Pigmentary glaucoma, right eye, severe stage H40.1314 Pigmentary glaucoma, right eye, indeterminate stage H40.1321 Pigmentary glaucoma, left eye, mild stage H40.1322 Pigmentary glaucoma, left eye, moderate stage H40.1323 Pigmentary glaucoma, left eye, severe stage H40.1324 Pigmentary glaucoma, left eye, indeterminate stage H40.1331 Pigmentary glaucoma, bilateral, mild stage H40.1332 Pigmentary glaucoma, bilateral, moderate stage H40.1333 Pigmentary glaucoma, bilateral, severe stage H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage H40.151 Residual stage of open-angle glaucoma, right eye H40.152 Residual stage of open-angle glaucoma, left eye H40.153 Residual stage of open-angle glaucoma, bilateral H40.20X1 Unspecified primary angle-closure glaucoma, mild stage H40.20X2 Unspecified primary angle-closure glaucoma, moderate stage H40.20X3 Unspecified primary angle-closure glaucoma, severe stage H40.20X4 Unspecified primary angle-closure glaucoma, indeterminate stage H40.211 Acute angle-closure glaucoma, right eye H40.212 Acute angle-closure glaucoma, left eye H40.213 Acute angle-closure glaucoma, bilateral Printed on 1/29/2018. Page 8 of 31

ICD-10 Codes H40.2211 Chronic angle-closure glaucoma, right eye, mild stage H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage H40.2213 Chronic angle-closure glaucoma, right eye, severe stage H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage H40.2221 Chronic angle-closure glaucoma, left eye, mild stage H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage H40.2223 Chronic angle-closure glaucoma, left eye, severe stage H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage H40.231 Intermittent angle-closure glaucoma, right eye H40.232 Intermittent angle-closure glaucoma, left eye H40.233 Intermittent angle-closure glaucoma, bilateral H40.241 Residual stage of angle-closure glaucoma, right eye H40.242 Residual stage of angle-closure glaucoma, left eye H40.243 Residual stage of angle-closure glaucoma, bilateral H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage H40.33X4 Glaucoma secondary to eye trauma, bilateral, indeterminate stage H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage H40.41X2 Glaucoma secondary to eye inflammation, right eye, moderate stage H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage H40.41X4 Glaucoma secondary to eye inflammation, right eye, indeterminate stage H40.42X1 Glaucoma secondary to eye inflammation, left eye, mild stage H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage H40.42X3 Glaucoma secondary to eye inflammation, left eye, severe stage H40.42X4 Glaucoma secondary to eye inflammation, left eye, indeterminate stage H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage H40.61X1 Glaucoma secondary to drugs, right eye, mild stage H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage H40.61X3 Glaucoma secondary to drugs, right eye, severe stage H40.61X4 Glaucoma secondary to drugs, right eye, indeterminate stage Printed on 1/29/2018. Page 9 of 31

ICD-10 Codes H40.62X1 Glaucoma secondary to drugs, left eye, mild stage H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage H40.62X3 Glaucoma secondary to drugs, left eye, severe stage H40.62X4 Glaucoma secondary to drugs, left eye, indeterminate stage H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage H40.63X4 Glaucoma secondary to drugs, bilateral, indeterminate stage H40.811 Glaucoma with increased episcleral venous pressure, right eye H40.812 Glaucoma with increased episcleral venous pressure, left eye H40.813 Glaucoma with increased episcleral venous pressure, bilateral H40.821 Hypersecretion glaucoma, right eye H40.822 Hypersecretion glaucoma, left eye H40.823 Hypersecretion glaucoma, bilateral H40.831 Aqueous misdirection, right eye H40.832 Aqueous misdirection, left eye H40.833 Aqueous misdirection, bilateral H40.89 Other specified glaucoma H42 Glaucoma in diseases classified elsewhere Q15.0 Congenital glaucoma Group 3 Paragraph: 92134 Group 3 Codes: ICD-10 Codes 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 E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye E08.3313 Printed on 1/29/2018. Page 10 of 31

ICD-10 Codes Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye E08.3593 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 E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema Printed on 1/29/2018. Page 11 of 31

ICD-10 Codes E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E09.3543 Printed on 1/29/2018. Page 12 of 31

ICD-10 Codes Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E09.3593 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 E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Printed on 1/29/2018. Page 13 of 31

ICD-10 Codes E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 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 E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Printed on 1/29/2018. Page 14 of 31

ICD-10 Codes E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral 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 E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Printed on 1/29/2018. Page 15 of 31