LCD Reference Article Billing and Coding Article

Billing and Coding: Electroretinography (ERG)

A58706

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

Article Information

General Information

Article ID
A58706

Article Title
Billing and Coding: Electroretinography (ERG)

Article Type
Billing and Coding

Original Effective Date
01/30/2022

Revision Effective Date
11/16/2023

Revision Ending Date
N/A

Retirement Date
N/A

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.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

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.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.

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 other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-04, Medicare Claims Manual, chapter 12:

40.1.A. Global surgery period

Article Guidance

Article Text

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Coding Guidelines

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. It is the provider's responsibility to select codes to the highest level of specificity from the ICD 10-CM code book appropriate to the year which the services rendered for the claim(s) submitted.
When reporting ICD-10 code Z79.899, the medical record must reflect the medication administered as well as the underlying condition for which it was given.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Compliance with the provisions in LCD DL38992, Electroretinography (ERG) may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(570 Codes)

Group 1 Paragraph

The ICD 10-CM diagnostic codes in Group 1 support the medical necessity of CPT codes 92273, 92274 and 0509T.

ICD-10 code D18.09 is to be reported for “retinal” hemangioma.

ICD-10 code Z79.899 Is to be reported for patients receiving vigabatrin, chlorpromazine, chloroquine or hydroxychloroquine begin evaluated for retinal toxicity.

Group 1 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
H36.811	Nonproliferative sickle-cell retinopathy, right eye
H36.812	Nonproliferative sickle-cell retinopathy, left eye
H36.813	Nonproliferative sickle-cell retinopathy, bilateral
H36.821	Proliferative sickle-cell retinopathy, right eye
H36.822	Proliferative sickle-cell retinopathy, left eye
H36.823	Proliferative sickle-cell retinopathy, bilateral
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
H53.54	Protanomaly
H53.55	Tritanomaly
H53.61	Abnormal dark adaptation curve
H53.62	Acquired night blindness
H53.63	Congenital night blindness
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
Z79.899	Other long term (current) drug therapy

ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Bill Type Codes

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

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Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
11/16/2023	R3	Revision Effective: 11/16/2023 Revision Explanation: Updated LCD Reference Article section.
10/01/2023	R2	Revision Effective 10/01/2023 Revision Explanation: Annual ICD-10 Update. Deleted the following from Group 1 H36 and added the following: H36.811, H36.812, H36.813, H36.821, H36.822, H36.823, and H36.89
01/30/2022	R1	Revision Effective 01/30/2022 Revision Explanation: Added ICD-10 codes H53.51-H53.55 and H53.61-H53.63 to group 1 as these were left off in error.

Associated Documents

Related Local Coverage Documents
LCDs
L38992 - Electroretinography (ERG)

Updated On	Effective Dates	Status
11/08/2023	11/16/2023 - N/A	Currently in Effect	You are here
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Billing and Coding: Electroretinography (ERG)

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