LCD Reference Article Billing and Coding Article

Billing and Coding: Visual Electrophysiology Testing

A57599

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A57599
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Visual Electrophysiology Testing
Article Type
Billing and Coding
Original Effective Date
11/01/2019
Revision Effective Date
11/30/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act Section 1833(e) 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) 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.

Code of Federal Regulations 42 CFR Section 410.32 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), who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or another qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Coverage Indications, Limitations, and/or Medical Necessity") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the MAC upon request.

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Group 1

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(134 Codes)
Group 1 Paragraph

The diagnosis codes in Group 1 below support the medical necessity of CPT code 95930 only. Diagnosis codes must be coded to the highest level of specificity. For codes in the table below that require a 7th character: A - initial encounter, D - subsequent encounter, or S – sequela may be used.

Group 1 Codes
Code Description
F44.6 Conversion disorder with sensory symptom or deficit
G35 Multiple sclerosis
H46.01 - H46.03 Optic papillitis, right eye - Optic papillitis, bilateral
H46.11 - H46.13 Retrobulbar neuritis, right eye - Retrobulbar neuritis, bilateral
H46.2 - H46.9 Nutritional optic neuropathy - Unspecified optic neuritis
H47.011 - H47.013 Ischemic optic neuropathy, right eye - Ischemic optic neuropathy, bilateral
H47.021 - H47.023 Hemorrhage in optic nerve sheath, right eye - Hemorrhage in optic nerve sheath, bilateral
H47.031 - H47.033 Optic nerve hypoplasia, right eye - Optic nerve hypoplasia, bilateral
H47.091 - H47.093 Other disorders of optic nerve, not elsewhere classified, right eye - Other disorders of optic nerve, not elsewhere classified, bilateral
H47.10 - H47.13 Unspecified papilledema - Papilledema associated with retinal disorder
H47.141 - H47.143 Foster-Kennedy syndrome, right eye - Foster-Kennedy syndrome, bilateral
H47.20 - H47.213 Unspecified optic atrophy - Primary optic atrophy, bilateral
H47.22 - H47.233 Hereditary optic atrophy - Glaucomatous optic atrophy, bilateral
H47.291 - H47.293 Other optic atrophy, right eye - Other optic atrophy, bilateral
H47.311 - H47.313 Coloboma of optic disc, right eye - Coloboma of optic disc, bilateral
H47.321 - H47.323 Drusen of optic disc, right eye - Drusen of optic disc, bilateral
H47.331 - H47.333 Pseudopapilledema of optic disc, right eye - Pseudopapilledema of optic disc, bilateral
H47.391 - H47.393 Other disorders of optic disc, right eye - Other disorders of optic disc, bilateral
H47.41 - H47.49 Disorders of optic chiasm in (due to) inflammatory disorders - Disorders of optic chiasm in (due to) other disorders
H47.521 - H47.522 Disorders of visual pathways in (due to) neoplasm, right side - Disorders of visual pathways in (due to) neoplasm, left side
H53.011 - H53.013 Deprivation amblyopia, right eye - Deprivation amblyopia, bilateral
H53.021 - H53.023 Refractive amblyopia, right eye - Refractive amblyopia, bilateral
H53.031 - H53.033 Strabismic amblyopia, right eye - Strabismic amblyopia, bilateral
H54.0X33 Blindness right eye category 3, blindness left eye category 3
H54.0X34 Blindness right eye category 3, blindness left eye category 4
H54.0X35 Blindness right eye category 3, blindness left eye category 5
H54.0X43 Blindness right eye category 4, blindness left eye category 3
H54.0X44 Blindness right eye category 4, blindness left eye category 4
H54.0X45 Blindness right eye category 4, blindness left eye category 5
H54.0X53 Blindness right eye category 5, blindness left eye category 3
H54.0X54 Blindness right eye category 5, blindness left eye category 4
H54.0X55 Blindness right eye category 5, blindness left eye category 5
H54.1131 Blindness right eye category 3, low vision left eye category 1
H54.1132 Blindness right eye category 3, low vision left eye category 2
H54.1141 Blindness right eye category 4, low vision left eye category 1
H54.1142 Blindness right eye category 4, low vision left eye category 2
H54.1151 Blindness right eye category 5, low vision left eye category 1
H54.1152 Blindness right eye category 5, low vision left eye category 2
H54.1213 Low vision right eye category 1, blindness left eye category 3
H54.1214 Low vision right eye category 1, blindness left eye category 4
H54.1215 Low vision right eye category 1, blindness left eye category 5
H54.1223 Low vision right eye category 2, blindness left eye category 3
H54.1224 Low vision right eye category 2, blindness left eye category 4
H54.1225 Low vision right eye category 2, blindness left eye category 5
H54.2X11 Low vision right eye category 1, low vision left eye category 1
H54.2X12 Low vision right eye category 1, low vision left eye category 2
H54.2X21 Low vision right eye category 2, low vision left eye category 1
H54.2X22 Low vision right eye category 2, low vision left eye category 2
H54.3 Unqualified visual loss, both eyes
H54.413A Blindness right eye category 3, normal vision left eye
H54.414A Blindness right eye category 4, normal vision left eye
H54.415A Blindness right eye category 5, normal vision left eye
H54.42A3 Blindness left eye category 3, normal vision right eye
H54.42A4 Blindness left eye category 4, normal vision right eye
H54.42A5 Blindness left eye category 5, normal vision right eye
H54.511A Low vision right eye category 1, normal vision left eye
H54.512A Low vision right eye category 2, normal vision left eye
H54.52A1 Low vision left eye category 1, normal vision right eye
H54.52A2 Low vision left eye category 2, normal vision right eye
H54.61 - H54.62 Unqualified visual loss, right eye, normal vision left eye - Unqualified visual loss, left eye, normal vision right eye
H54.7 - H54.8 Unspecified visual loss - Legal blindness, as defined in USA
S04.011A - S04.042A Injury of optic nerve, right eye, initial encounter - Injury of visual cortex, left side, initial encounter

Group 2

(564 Codes)
Group 2 Paragraph

The diagnosis codes in Group 2 below support the medical necessity of CPT codes 92273, 92274, and 0509T only. Diagnosis codes must be coded to the highest level of specificity. For codes in the table below that require a 7th character: A - initial encounter, D - subsequent encounter, or S – sequela may be used.

Group 2 Codes
Code Description
A18.53 Tuberculous chorioretinitis
B50.0 Plasmodium falciparum malaria with cerebral complications
B50.8 Other severe and complicated Plasmodium falciparum malaria
B50.9 Plasmodium falciparum malaria, unspecified
D18.09 Hemangioma of other sites
E08.311 - E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema - Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.3211 - E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye - Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3291 - E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye - Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3311 - E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3391 - E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye - Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3411 - E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye - Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3491 - E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye - Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3511 - E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3521 - E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3531 - E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3541 - E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3551 - E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye - Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3591 - E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral
E09.311 - E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema - Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.3211 - E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3291 - E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye - Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3311 - E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3391 - E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye - Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3411 - E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3491 - E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye - Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3511 - E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E09.3521 - E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E09.3531 - E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E09.3541 - E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E09.3551 - E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye - Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E09.3591 - E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E10.311 - E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.3211 - E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3291 - E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3311 - E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3391 - E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3411 - E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3491 - E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3511 - E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3521 - E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3531 - E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3541 - E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E10.3551 - E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye - Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E10.3591 - E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.311 - E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211 - E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3291 - E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3311 - E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3391 - E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3411 - E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3491 - E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3511 - E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3521 - E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E11.3531 - E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E11.3541 - E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3551 - E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye - Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3591 - E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E13.311 - E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema - Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.3211 - E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3291 - E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3311 - E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3391 - E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3411 - E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3491 - E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3511 - E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E13.3521 - E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E13.3531 - E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E13.3541 - E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E13.3551 - E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye - Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E13.3591 - E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
G45.3 Amaurosis fugax
H30.001 - H30.003 Unspecified focal chorioretinal inflammation, right eye - Unspecified focal chorioretinal inflammation, bilateral
H30.011 - H30.013 Focal chorioretinal inflammation, juxtapapillary, right eye - Focal chorioretinal inflammation, juxtapapillary, bilateral
H30.021 - H30.023 Focal chorioretinal inflammation of posterior pole, right eye - Focal chorioretinal inflammation of posterior pole, bilateral
H30.031 - H30.033 Focal chorioretinal inflammation, peripheral, right eye - Focal chorioretinal inflammation, peripheral, bilateral
H30.041 - H30.043 Focal chorioretinal inflammation, macular or paramacular, right eye - Focal chorioretinal inflammation, macular or paramacular, bilateral
H30.101 - H30.103 Unspecified disseminated chorioretinal inflammation, right eye - Unspecified disseminated chorioretinal inflammation, bilateral
H30.111 - H30.113 Disseminated chorioretinal inflammation of posterior pole, right eye - Disseminated chorioretinal inflammation of posterior pole, bilateral
H30.121 - H30.123 Disseminated chorioretinal inflammation, peripheral right eye - Disseminated chorioretinal inflammation, peripheral, bilateral
H30.131 - H30.133 Disseminated chorioretinal inflammation, generalized, right eye - Disseminated chorioretinal inflammation, generalized, bilateral
H30.141 - H30.143 Acute posterior multifocal placoid pigment epitheliopathy, right eye - Acute posterior multifocal placoid pigment epitheliopathy, bilateral
H30.21 - H30.23 Posterior cyclitis, right eye - Posterior cyclitis, bilateral
H30.811 - H30.813 Harada's disease, right eye - Harada's disease, bilateral
H30.891 - H30.893 Other chorioretinal inflammations, right eye - Other chorioretinal inflammations, bilateral
H30.91 - H30.93 Unspecified chorioretinal inflammation, right eye - Unspecified chorioretinal inflammation, bilateral
H31.001 - H31.003 Unspecified chorioretinal scars, right eye - Unspecified chorioretinal scars, bilateral
H31.011 - H31.013 Macula scars of posterior pole (postinflammatory) (post-traumatic), right eye - Macula scars of posterior pole (postinflammatory) (post-traumatic), bilateral
H31.021 - H31.023 Solar retinopathy, right eye - Solar retinopathy, bilateral
H31.091 - H31.093 Other chorioretinal scars, right eye - Other chorioretinal scars, bilateral
H31.101 - H31.103 Choroidal degeneration, unspecified, right eye - Choroidal degeneration, unspecified, bilateral
H31.111 - H31.113 Age-related choroidal atrophy, right eye - Age-related choroidal atrophy, bilateral
H31.121 - H31.123 Diffuse secondary atrophy of choroid, right eye - Diffuse secondary atrophy of choroid, bilateral
H31.20 Hereditary choroidal dystrophy, unspecified
H31.21 Choroideremia
H31.22 Choroidal dystrophy (central areolar) (generalized) (peripapillary)
H31.23 Gyrate atrophy, choroid
H31.29 Other hereditary choroidal dystrophy
H31.301 - H31.303 Unspecified choroidal hemorrhage, right eye - Unspecified choroidal hemorrhage, bilateral
H31.311 - H31.313 Expulsive choroidal hemorrhage, right eye - Expulsive choroidal hemorrhage, bilateral
H31.321 - H31.323 Choroidal rupture, right eye - Choroidal rupture, bilateral
H31.401 - H31.403 Unspecified choroidal detachment, right eye - Unspecified choroidal detachment, bilateral
H31.411 - H31.413 Hemorrhagic choroidal detachment, right eye - Hemorrhagic choroidal detachment, bilateral
H31.421 - H31.423 Serous choroidal detachment, right eye - Serous choroidal detachment, bilateral
H33.001 - H33.003 Unspecified retinal detachment with retinal break, right eye - Unspecified retinal detachment with retinal break, bilateral
H33.011 - H33.013 Retinal detachment with single break, right eye - Retinal detachment with single break, bilateral
H33.021 - H33.023 Retinal detachment with multiple breaks, right eye - Retinal detachment with multiple breaks, bilateral
H33.031 - H33.033 Retinal detachment with giant retinal tear, right eye - Retinal detachment with giant retinal tear, bilateral
H33.041 - H33.043 Retinal detachment with retinal dialysis, right eye - Retinal detachment with retinal dialysis, bilateral
H33.051 - H33.053 Total retinal detachment, right eye - Total retinal detachment, bilateral
H33.101 - H33.103 Unspecified retinoschisis, right eye - Unspecified retinoschisis, bilateral
H33.111 - H33.113 Cyst of ora serrata, right eye - Cyst of ora serrata, bilateral
H33.191 - H33.193 Other retinoschisis and retinal cysts, right eye - Other retinoschisis and retinal cysts, bilateral
H33.21 - H33.23 Serous retinal detachment, right eye - Serous retinal detachment, bilateral
H33.301 - H33.303 Unspecified retinal break, right eye - Unspecified retinal break, bilateral
H33.311 - H33.313 Horseshoe tear of retina without detachment, right eye - Horseshoe tear of retina without detachment, bilateral
H33.321 - H33.323 Round hole, right eye - Round hole, bilateral
H33.331 - H33.333 Multiple defects of retina without detachment, right eye - Multiple defects of retina without detachment, bilateral
H33.41 - H33.43 Traction detachment of retina, right eye - Traction detachment of retina, bilateral
H33.8 Other retinal detachments
H34.01 - H34.03 Transient retinal artery occlusion, right eye - Transient retinal artery occlusion, bilateral
H34.11 - H34.13 Central retinal artery occlusion, right eye - Central retinal artery occlusion, bilateral
H34.211 - H34.213 Partial retinal artery occlusion, right eye - Partial retinal artery occlusion, bilateral
H34.231 - H34.233 Retinal artery branch occlusion, right eye - Retinal artery branch occlusion, bilateral
H34.8110 - H34.8112 Central retinal vein occlusion, right eye, with macular edema - Central retinal vein occlusion, right eye, stable
H34.8120 - H34.8122 Central retinal vein occlusion, left eye, with macular edema - Central retinal vein occlusion, left eye, stable
H34.8130 - H34.8132 Central retinal vein occlusion, bilateral, with macular edema - Central retinal vein occlusion, bilateral, stable
H34.821 - H34.823 Venous engorgement, right eye - Venous engorgement, bilateral
H34.8310 - H34.8312 Tributary (branch) retinal vein occlusion, right eye, with macular edema - Tributary (branch) retinal vein occlusion, right eye, stable
H34.8320 - H34.8322 Tributary (branch) retinal vein occlusion, left eye, with macular edema - Tributary (branch) retinal vein occlusion, left eye, stable
H34.8330 - H34.8332 Tributary (branch) retinal vein occlusion, bilateral, with macular edema - Tributary (branch) retinal vein occlusion, bilateral, stable
H34.9 Unspecified retinal vascular occlusion
H35.00 Unspecified background retinopathy
H35.011 - H35.013 Changes in retinal vascular appearance, right eye - Changes in retinal vascular appearance, bilateral
H35.021 - H35.023 Exudative retinopathy, right eye - Exudative retinopathy, bilateral
H35.031 - H35.033 Hypertensive retinopathy, right eye - Hypertensive retinopathy, bilateral
H35.041 - H35.043 Retinal micro-aneurysms, unspecified, right eye - Retinal micro-aneurysms, unspecified, bilateral
H35.051 - H35.053 Retinal neovascularization, unspecified, right eye - Retinal neovascularization, unspecified, bilateral
H35.061 - H35.063 Retinal vasculitis, right eye - Retinal vasculitis, bilateral
H35.071 - H35.073 Retinal telangiectasis, right eye - Retinal telangiectasis, bilateral
H35.09 Other intraretinal microvascular abnormalities
H35.101 - H35.103 Retinopathy of prematurity, unspecified, right eye - Retinopathy of prematurity, unspecified, bilateral
H35.111 - H35.113 Retinopathy of prematurity, stage 0, right eye - Retinopathy of prematurity, stage 0, bilateral
H35.121 - H35.123 Retinopathy of prematurity, stage 1, right eye - Retinopathy of prematurity, stage 1, bilateral
H35.131 - H35.133 Retinopathy of prematurity, stage 2, right eye - Retinopathy of prematurity, stage 2, bilateral
H35.141 - H35.143 Retinopathy of prematurity, stage 3, right eye - Retinopathy of prematurity, stage 3, bilateral
H35.151 - H35.153 Retinopathy of prematurity, stage 4, right eye - Retinopathy of prematurity, stage 4, bilateral
H35.161 - H35.163 Retinopathy of prematurity, stage 5, right eye - Retinopathy of prematurity, stage 5, bilateral
H35.171 - H35.173 Retrolental fibroplasia, right eye - Retrolental fibroplasia, bilateral
H35.21 - H35.23 Other non-diabetic proliferative retinopathy, right eye - Other non-diabetic proliferative retinopathy, bilateral
H35.30 Unspecified macular degeneration
H35.3110 - H35.3134 Nonexudative age-related macular degeneration, right eye, stage unspecified - Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement
H35.3210 - H35.3233 Exudative age-related macular degeneration, right eye, stage unspecified - Exudative age-related macular degeneration, bilateral, with inactive scar
H35.33 Angioid streaks of macula
H35.341 - H35.343 Macular cyst, hole, or pseudohole, right eye - Macular cyst, hole, or pseudohole, bilateral
H35.351 - H35.353 Cystoid macular degeneration, right eye - Cystoid macular degeneration, bilateral
H35.361 - H35.363 Drusen (degenerative) of macula, right eye - Drusen (degenerative) of macula, bilateral
H35.371 - H35.373 Puckering of macula, right eye - Puckering of macula, bilateral
H35.381 - H35.383 Toxic maculopathy, right eye - Toxic maculopathy, bilateral
H35.40 Unspecified peripheral retinal degeneration
H35.411 - H35.413 Lattice degeneration of retina, right eye - Lattice degeneration of retina, bilateral
H35.421 - H35.423 Microcystoid degeneration of retina, right eye - Microcystoid degeneration of retina, bilateral
H35.431 - H35.433 Paving stone degeneration of retina, right eye - Paving stone degeneration of retina, bilateral
H35.441 - H35.443 Age-related reticular degeneration of retina, right eye - Age-related reticular degeneration of retina, bilateral
H35.451 - H35.453 Secondary pigmentary degeneration, right eye - Secondary pigmentary degeneration, bilateral
H35.461 - H35.463 Secondary vitreoretinal degeneration, right eye - Secondary vitreoretinal degeneration, bilateral
H35.50 - H35.54 Unspecified hereditary retinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium
H35.61 - H35.63 Retinal hemorrhage, right eye - Retinal hemorrhage, bilateral
H35.70 Unspecified separation of retinal layers
H35.711 - H35.713 Central serous chorioretinopathy, right eye - Central serous chorioretinopathy, bilateral
H35.721 - H35.723 Serous detachment of retinal pigment epithelium, right eye - Serous detachment of retinal pigment epithelium, bilateral
H35.731 - H35.733 Hemorrhagic detachment of retinal pigment epithelium, right eye - Hemorrhagic detachment of retinal pigment epithelium, bilateral
H35.81 - H35.89 Retinal edema - Other specified retinal disorders
H36.89 Other retinal disorders in diseases classified elsewhere
H46.01 - H46.03 Optic papillitis, right eye - Optic papillitis, bilateral
H46.11 - H46.13 Retrobulbar neuritis, right eye - Retrobulbar neuritis, bilateral
H46.2 - H46.9 Nutritional optic neuropathy - Unspecified optic neuritis
H47.011 - H47.013 Ischemic optic neuropathy, right eye - Ischemic optic neuropathy, bilateral
H47.021 - H47.023 Hemorrhage in optic nerve sheath, right eye - Hemorrhage in optic nerve sheath, bilateral
H47.031 - H47.033 Optic nerve hypoplasia, right eye - Optic nerve hypoplasia, bilateral
H47.091 - H47.093 Other disorders of optic nerve, not elsewhere classified, right eye - Other disorders of optic nerve, not elsewhere classified, bilateral
H47.10 - H47.13 Unspecified papilledema - Papilledema associated with retinal disorder
H47.141 - H47.143 Foster-Kennedy syndrome, right eye - Foster-Kennedy syndrome, bilateral
H47.20 - H47.213 Unspecified optic atrophy - Primary optic atrophy, bilateral
H47.22 - H47.233 Hereditary optic atrophy - Glaucomatous optic atrophy, bilateral
H47.291 - H47.293 Other optic atrophy, right eye - Other optic atrophy, bilateral
H47.311 - H47.313 Coloboma of optic disc, right eye - Coloboma of optic disc, bilateral
H47.321 - H47.323 Drusen of optic disc, right eye - Drusen of optic disc, bilateral
H47.331 - H47.333 Pseudopapilledema of optic disc, right eye - Pseudopapilledema of optic disc, bilateral
H47.391 - H47.393 Other disorders of optic disc, right eye - Other disorders of optic disc, bilateral
H53.51 Achromatopsia
H53.52 Acquired color vision deficiency
H53.53 Deuteranomaly
H53.60 Unspecified night blindness
H53.63 Congenital night blindness
H53.8 Other visual disturbances
H53.9 Unspecified visual disturbance
L10.4 Pemphigus erythematosus
T37.2X1A Poisoning by antimalarials and drugs acting on other blood protozoa, accidental (unintentional), initial encounter
T37.2X2A Poisoning by antimalarials and drugs acting on other blood protozoa, intentional self-harm, initial encounter
T37.2X3A Poisoning by antimalarials and drugs acting on other blood protozoa, assault, initial encounter
T37.2X4A Poisoning by antimalarials and drugs acting on other blood protozoa, undetermined, initial encounter
T37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter
T37.2X6A Underdosing of antimalarials and drugs acting on other blood protozoa, initial encounter
Z79.899 Other long term (current) drug therapy
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/30/2023 R4

Posted 11/30/2023: Under ICD-10 Codes that Support Medical Necessity Group 2 Codes added ICD-10 codes H53.63, H53.51, H53.52, and H53.53 per provider request.

10/01/2023 R3

Posted 09/28/2023: Biannual review completed 08/14/2023 with minor grammatical changes made. Under ICD-10 Codes that Support Medical Necessity Group 2 Codes added ICD-10 code H36.89 and deleted ICD-10 code H36 due to the 2024 Annual ICD-10-CM update which will be effective 10/01/2023.

10/28/2021 R2

10/28/2021 Review completed 09/28/2021 with no change in coverage. Minor punctuation corrections were made in the article.

12/31/2020 R1

12/31/2020 CPT/HCPCS Group 2 Code and ICD-10 Group 2 Paragraph added: CPT 0509T Electroretinography (ERG) with interpretation and report, pattern (PERG).

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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