LCD Reference Article Billing and Coding Article

Billing and Coding: Cataract Extraction

A56453

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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
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Article ID
A56453
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Cataract Extraction
Article Type
Billing and Coding
Original Effective Date
10/01/2016
Revision Effective Date
01/04/2024
Revision Ending Date
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Retirement Date
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Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33954 Cataract Extraction.

 

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.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

For CPT code 66982, complex cataract extraction, to be reasonable and necessary, the procedure should require devices or techniques not generally used in routine cataract surgery.

 

ICD-10-CM DOCUMENTATION REQUIREMENTS for COMPLEX CATARACT SURGERY (CPT Code 66982)
H20.21-H20.23, H21.261-H21.263, H21.29, H21.561-H21.563 Report if the operative note indicates the use of an endocapsular ring to partially occlude the pupil.
H21.271-H21.273, H26.211-H26.213, H26.221-H26.223, Report if the operative note indicates micro iris hooks were inserted through four (4) separate corneal incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers or, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of the iris sphincter.
H21.221-H21.223 Report if the operative note indicates that a permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position.
H21.531-H21.533 Report if the operative note indicates a capsular support ring was employed or an endocapsular support ring was used for partial occlusion of the pupil.
H21.81, H21.89, H21.9,H22, H25.011-H25.013, H25.11-H25.13, H25.031-H25.033, H25.041-H25.043, H25.811-H25.813, H25.89, H25.9, H26.001-H26.003, H26.011-H26.013,H26.031-H26.033, H26.041-H26.043 H26.051-H26.053, H26.061-H26.063, H26.09, H26.121-H26.123, H26.31-H26.33, H26.8, H28, E08.36, E09.36, E10.36, E11.36, E13.36, Q13.0, Q13.2 Report if the operative note indicates the use of micro iris hooks inserted through four (4) separate cornea incisions, use of a Beechler or similar expansion device, synechialysis utiliziaing papillary stretch maneuvers creation of multiple sphincterotomies with scissors, a sector iridotomy with suture repair of iris sphincter was performed, or a permanent intraocular suture, capsular support ring, or endocapsular support ring was used for partial occlusion of the pupil.
H25.89 Report if the operative note indicates dye was used to stain the anterior capsule.
H25.21-H25.23 This code must be used with H40.89– Phacolytic glaucoma or dye staining of the anterior capsule.
H26.101-H26.103, H26.111-H26.113, H26.131-H26.133, H26.20 Report if the operative note indicates micro iris hooks were inserted through four (4) separate corneal incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, intraocular lens implant was supported by using a permanent intraocular sutures, a capsular support ring was employed or a primary posteriod capsulorhexis was performed.
H28 Report if the operative note or postoperative records indicate an extraordinary amount of work was involved in the preoperative or postoperative care.
H27.10, H27.111-H27.113, H27.121-H27.123,
H27.131-H27.133, Q12.1, Q12.2, Q12.4, Q12.8, Q12.9
Report if the operative note indicates: the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring.
H57.00-H57.04, H57.051-H57.053, H57.09, H57.9 Report if the operative note indicates the use of micro iris hooks inserted through four (4) separate incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers, multiple sphincterotomies created with scissors, a sector iridotomy with suture repair of the iris sphincter, or an artificial prosthetic iris was placed in the eye.
Q13.1 Report if the operative note indicates the intraocular lens was supported in the eye by using permanent intraocular sutures, a capsular support ring was employed, or an endocapsular ring was used to for partial occlusion of the pupil.

 

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Coding Information

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(225 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Group 1 Codes
Code Description
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
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
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
E09.3521 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 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
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
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
E10.3521 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
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
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
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
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
H20.21 - H20.23 Lens-induced iridocyclitis, right eye - Lens-induced iridocyclitis, bilateral
H25.011 - H25.013 Cortical age-related cataract, right eye - Cortical age-related cataract, bilateral
H25.031 - H25.033 Anterior subcapsular polar age-related cataract, right eye - Anterior subcapsular polar age-related cataract, bilateral
H25.041 - H25.043 Posterior subcapsular polar age-related cataract, right eye - Posterior subcapsular polar age-related cataract, bilateral
H25.11 - H25.13 Age-related nuclear cataract, right eye - Age-related nuclear cataract, bilateral
H25.21 - H25.23 Age-related cataract, morgagnian type, right eye - Age-related cataract, morgagnian type, bilateral
H25.811 - H25.813 Combined forms of age-related cataract, right eye - Combined forms of age-related cataract, bilateral
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 - H26.003 Unspecified infantile and juvenile cataract, right eye - Unspecified infantile and juvenile cataract, bilateral
H26.011 - H26.013 Infantile and juvenile cortical, lamellar, or zonular cataract, right eye - Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral
H26.031 - H26.033 Infantile and juvenile nuclear cataract, right eye - Infantile and juvenile nuclear cataract, bilateral
H26.041 - H26.043 Anterior subcapsular polar infantile and juvenile cataract, right eye - Anterior subcapsular polar infantile and juvenile cataract, bilateral
H26.051 - H26.053 Posterior subcapsular polar infantile and juvenile cataract, right eye - Posterior subcapsular polar infantile and juvenile cataract, bilateral
H26.061 - H26.063 Combined forms of infantile and juvenile cataract, right eye - Combined forms of infantile and juvenile cataract, bilateral
H26.09 Other infantile and juvenile cataract
H26.101 - H26.103 Unspecified traumatic cataract, right eye - Unspecified traumatic cataract, bilateral
H26.111 - H26.113 Localized traumatic opacities, right eye - Localized traumatic opacities, bilateral
H26.121 - H26.123 Partially resolved traumatic cataract, right eye - Partially resolved traumatic cataract, bilateral
H26.131 - H26.133 Total traumatic cataract, right eye - Total traumatic cataract, bilateral
H26.20 Unspecified complicated cataract
H26.211 - H26.213 Cataract with neovascularization, right eye - Cataract with neovascularization, bilateral
H26.221 - H26.223 Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye - Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral
H26.231 - H26.233 Glaucomatous flecks (subcapsular), right eye - Glaucomatous flecks (subcapsular), bilateral
H26.31 - H26.33 Drug-induced cataract, right eye - Drug-induced cataract, bilateral
H26.9 Unspecified cataract
H27.10 Unspecified dislocation of lens
H27.111 - H27.113 Subluxation of lens, right eye - Subluxation of lens, bilateral
H27.121 - H27.123 Anterior dislocation of lens, right eye - Anterior dislocation of lens, bilateral
H27.131 - H27.133 Posterior dislocation of lens, right eye - Posterior dislocation of lens, bilateral
H28 Cataract in diseases classified elsewhere
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
H33.8 Other retinal detachments
H35.81 Retinal edema
H40.1210 - H40.1214 Low-tension glaucoma, right eye, stage unspecified - Low-tension glaucoma, right eye, indeterminate stage
H40.1220 - H40.1224 Low-tension glaucoma, left eye, stage unspecified - Low-tension glaucoma, left eye, indeterminate stage
H40.1230 - H40.1234 Low-tension glaucoma, bilateral, stage unspecified - Low-tension glaucoma, bilateral, indeterminate stage
H40.1310 - H40.1314 Pigmentary glaucoma, right eye, stage unspecified - Pigmentary glaucoma, right eye, indeterminate stage
H40.1320 - H40.1324 Pigmentary glaucoma, left eye, stage unspecified - Pigmentary glaucoma, left eye, indeterminate stage
H40.1330 - H40.1334 Pigmentary glaucoma, bilateral, stage unspecified - Pigmentary glaucoma, bilateral, indeterminate stage
H40.89 Other specified glaucoma
H43.11 - H43.13 Vitreous hemorrhage, right eye - Vitreous hemorrhage, bilateral
H43.821 - H43.823 Vitreomacular adhesion, right eye - Vitreomacular adhesion, bilateral
H52.31 Anisometropia
Q12.1 - Q12.4 Congenital displaced lens - Spherophakia
Q12.8 Other congenital lens malformations
Q12.9 Congenital lens malformation, unspecified
Z83.511 Family history of glaucoma
Z83.518 Family history of other specified eye disorder

Group 2

(160 Codes)
Group 2 Paragraph

ICD-10-CM E08.311, E08.319, E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3591, E08.3592, E08.3593, E09.311, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3591, E09.3592, E09.3593, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3591, E10.3592, E10.3593, E11.319, E11.321, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.331, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3591, E11.3592, E11.3593, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.331, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.35113, E13.3591, E13.3592, E13.3593, H35.041-H35.043, H35.071-H35.073, H35.21-H35.23, H35.3211-H35.3213, H35.3221-H35.3223, H35.3231-H35.3233, H35.341-H35.343, H35.371-H35.373 require coding of the underlying diagnosis.

ICD-10-CM codes H59.021-H59.023 is only allowed for CPT codes 66840, 66850, and 66852.

ICD-10-CM code H26.491-H26.493 is only allowed for CPT codes 66840, 66850, 66852, 66920, and 66930.

Group 2 Codes
Code Description
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 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
E08.3591 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
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
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
E09.3591 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
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
E10.3591 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
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
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
E11.3591 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
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
E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
H26.491 - H26.493 Other secondary cataract, right eye - Other secondary cataract, bilateral
H35.041 - H35.043 Retinal micro-aneurysms, unspecified, right eye - Retinal micro-aneurysms, unspecified, bilateral
H35.071 - H35.073 Retinal telangiectasis, right eye - Retinal telangiectasis, bilateral
H35.21 - H35.23 Other non-diabetic proliferative retinopathy, right eye - Other non-diabetic proliferative retinopathy, bilateral
H35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularization
H35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization
H35.3213 Exudative age-related macular degeneration, right eye, with inactive scar
H35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization
H35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization
H35.3223 Exudative age-related macular degeneration, left eye, with inactive scar
H35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization
H35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization
H35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar
H35.341 - H35.343 Macular cyst, hole, or pseudohole, right eye - Macular cyst, hole, or pseudohole, bilateral
H35.371 - H35.373 Puckering of macula, right eye - Puckering of macula, bilateral
H59.021 - H59.023 Cataract (lens) fragments in eye following cataract surgery, right eye - Cataract (lens) fragments in eye following cataract surgery, bilateral

Group 3

(119 Codes)
Group 3 Paragraph

For CPT code 66982, in addition to reporting one of the primary diagnoses listed above, physicians/providers must report the appropriate ICD-10-CM code(s) from the secondary diagnosis list below, if not listed on the referenced primary diagnosis list. Please see the “Documentation Requirements” section of this LCD for medical necessity guidelines for the following diagnoses.

Group 3 Codes
Code Description
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E10.36 Type 1 diabetes mellitus with diabetic cataract
E11.36 Type 2 diabetes mellitus with diabetic cataract
E13.36 Other specified diabetes mellitus with diabetic cataract
H20.21 - H20.23 Lens-induced iridocyclitis, right eye - Lens-induced iridocyclitis, bilateral
H21.221 - H21.223 Degeneration of ciliary body, right eye - Degeneration of ciliary body, bilateral
H21.261 - H21.263 Iris atrophy (essential) (progressive), right eye - Iris atrophy (essential) (progressive), bilateral
H21.271 - H21.273 Miotic pupillary cyst, right eye - Miotic pupillary cyst, bilateral
H21.29 Other iris atrophy
H21.531 - H21.533 Iridodialysis, right eye - Iridodialysis, bilateral
H21.561 - H21.563 Pupillary abnormality, right eye - Pupillary abnormality, bilateral
H21.81 Floppy iris syndrome
H21.89 Other specified disorders of iris and ciliary body
H21.9 Unspecified disorder of iris and ciliary body
H22 Disorders of iris and ciliary body in diseases classified elsewhere
H25.011 Cortical age-related cataract, right eye
H25.012 Cortical age-related cataract, left eye
H25.013 Cortical age-related cataract, bilateral
H25.031 - H25.033 Anterior subcapsular polar age-related cataract, right eye - Anterior subcapsular polar age-related cataract, bilateral
H25.041 - H25.043 Posterior subcapsular polar age-related cataract, right eye - Posterior subcapsular polar age-related cataract, bilateral
H25.11 - H25.13 Age-related nuclear cataract, right eye - Age-related nuclear cataract, bilateral
H25.21 - H25.23 Age-related cataract, morgagnian type, right eye - Age-related cataract, morgagnian type, bilateral
H25.811 - H25.813 Combined forms of age-related cataract, right eye - Combined forms of age-related cataract, bilateral
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 - H26.003 Unspecified infantile and juvenile cataract, right eye - Unspecified infantile and juvenile cataract, bilateral
H26.011 - H26.013 Infantile and juvenile cortical, lamellar, or zonular cataract, right eye - Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral
H26.031 - H26.033 Infantile and juvenile nuclear cataract, right eye - Infantile and juvenile nuclear cataract, bilateral
H26.041 - H26.043 Anterior subcapsular polar infantile and juvenile cataract, right eye - Anterior subcapsular polar infantile and juvenile cataract, bilateral
H26.051 - H26.053 Posterior subcapsular polar infantile and juvenile cataract, right eye - Posterior subcapsular polar infantile and juvenile cataract, bilateral
H26.061 - H26.063 Combined forms of infantile and juvenile cataract, right eye - Combined forms of infantile and juvenile cataract, bilateral
H26.09 Other infantile and juvenile cataract
H26.101 - H26.103 Unspecified traumatic cataract, right eye - Unspecified traumatic cataract, bilateral
H26.111 - H26.113 Localized traumatic opacities, right eye - Localized traumatic opacities, bilateral
H26.121 - H26.123 Partially resolved traumatic cataract, right eye - Partially resolved traumatic cataract, bilateral
H26.131 - H26.133 Total traumatic cataract, right eye - Total traumatic cataract, bilateral
H26.20 Unspecified complicated cataract
H26.211 - H26.213 Cataract with neovascularization, right eye - Cataract with neovascularization, bilateral
H26.221 - H26.223 Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye - Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral
H26.31 - H26.33 Drug-induced cataract, right eye - Drug-induced cataract, bilateral
H26.8 Other specified cataract
H27.10 Unspecified dislocation of lens
H27.111 - H27.113 Subluxation of lens, right eye - Subluxation of lens, bilateral
H27.121 - H27.123 Anterior dislocation of lens, right eye - Anterior dislocation of lens, bilateral
H27.131 - H27.133 Posterior dislocation of lens, right eye - Posterior dislocation of lens, bilateral
H28 Cataract in diseases classified elsewhere
H57.00 - H57.04 Unspecified anomaly of pupillary function - Mydriasis
H57.051 - H57.053 Tonic pupil, right eye - Tonic pupil, bilateral
H57.09 Other anomalies of pupillary function
H57.9 Unspecified disorder of eye and adnexa
Q12.1 Congenital displaced lens
Q12.2 Coloboma of lens
Q12.4 Spherophakia
Q12.8 Other congenital lens malformations
Q12.9 Congenital lens malformation, unspecified
Q13.0 Coloboma of iris
Q13.1 Absence of iris
Q13.2 Other congenital malformations of iris
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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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Additional ICD-10 Information

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Bill Type Codes

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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.

Revenue codes only apply to providers who bill these services to the or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.


Code Description

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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

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01/04/2024 R6

R6

Revision Effective: 01/04/2024

Revision Explanation: Annual review, no changes.

11/16/2023 R5

R5

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

01/05/2023 R4

R4

Revision Effective: 01/05/2023
Revision Explanation: Annual review, no changes were made.

01/06/2022 R3

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Revision Effective: 1/6/2022
Revision Explanation: Annual review, no changes were made.

12/24/2020 R2

R2

Revision Effective: 12/24/2020
Revision Explanation: Annual review, no changes were made.

09/19/2019 R1

R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

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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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Updated On Effective Dates Status
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