Archive
API

Local Coverage Determination (LCD)

Visual Fields

L34615

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34615
Original ICD-9 LCD ID
Not Applicable
LCD Title
Visual Fields
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 06/29/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (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.

Issue

Issue Description

Biannual review completed with no change in coverage. Minor grammatical changes made throughout.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

CMS Pub 100-02, Medicare Benefit Policy Manual, Chapter 16 – General Exclusions From Coverage, Section 90 – Routine Services and Appliances.

42 CFR Section 410.32 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) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Visual fields are examined using static or kinetic perimetry. The procedure is performed separately for each eye, and measures the combined function of the retina, the optic nerve, and the intracranial visual pathway. It is used clinically to detect or monitor field loss due to disease at any of these locations. Visual fields may be determined by several methods including a tangent screen, Goldmann perimeter, and computerized automated perimeters.

Visual field examinations will be considered medically necessary under the following conditions:

  1. Disorder of the eyelids potentially affecting the visual field.

  2. A documented diagnosis of glaucoma.

    Stabilization or progression of glaucoma can be monitored by a visual field examination, or by such services as scanning computerized ophthalmic diagnostic imaging. This evaluation must be performed at regular intervals to determine that the prescribed management is adequately controlling progression of disease to the degree possible. The frequency of such examinations is dependent on clinical judgment as well as the variability of intraocular pressure measurements (e.g., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve.

  3. A diagnosis of glaucoma is suspected with supporting evidence documented.

    A suspected diagnosis of glaucoma is evidenced by an increase in intraocular pressure over time, intraocular pressures of 22 mm Hg or more, asymmetric intraocular measurements of greater than 2 mm Hg between the two eyes, or optic nerves suspicious for glaucoma, which may be manifested as asymmetrical cupping, a change in the cup-to-disc ratio over time, disc hemorrhage, or an absent, thinned, or notched neural rim. Additional possible indicators of glaucoma suspicion are fallout of the retinal nerve fiber layer, optic atrophy (pallor of the optic nerve), corneal endothelial pigment deposits (Krukenburg's Spindle), dense pigmentation of the trabecular meshwork as evidenced by gonioscopy, pseudoexfoliation of the lens, or dense exfoliative deposits on the trabecular meshwork as evidenced by gonioscopy.

  4. A documented disorder of the optic nerve, the neurologic visual pathway, or retina.

    Patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients who are about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field would not be indicated.

  5. A recent intracranial hemorrhage, an intracranial mass, or a recent measurement of increased intracranial pressure with or without visual symptomatology.

  6. A recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia, or giant cell arteritis.

  7. A history of a cerebral aneurysm, pituitary tumor, occipital tumor, or other condition potentially affecting the visual fields.

  8. A visual field defect demonstrated by gross visual field testing (e.g., confrontation testing).

  9. An initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital ptosis.

  10. A disorder of the orbit, potentially affecting the visual field (e.g., orbital tumor, thyroid disease, etc.).

  11. A significant eye injury.

  12. Unexplained visual loss which may be described as "trouble seeing or vision going in and out."

  13. A pale or swollen optic nerve documented by a recent examination.

  14. New functional limitations which may be due to visual field loss (e.g., reports by family that patient is running into things).

  15. Medication treatment (e.g., hydroxychloroquine) which has a high risk of potentially affecting the visual system.

  16. Initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70.

Limitations
Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological services and should not be reported separately.

Frequency of examinations for a diagnosis of macular degeneration or an experienced central vision loss (or to evaluate the results of a surgical intervention or for the possible need for surgical intervention) is dictated by stage of disease or degree of risk factors, just as with glaucoma evaluation.

Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed to verify that the services were medically reasonable and necessary.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Expand All | Collapse All

Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

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

Expand All | Collapse All

Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements
The medical record documentation must clearly indicate the medical necessity of the visual field testing and the results of the visual field test must be maintained in the patient's medical record.

Visual field testing is covered for diagnosis and treatment of abnormal signs, symptoms, disease, or injury.

The medical record must be made available to Medicare upon request.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination, (formerly appeal), providers must include all relevant documentation with the request.

There must always be a reason for performing the test since routine exams are considered screening and thus are not covered as medically reasonable and necessary.

Utilization Guidelines
The frequency of examinations for a diagnosis of macular degeneration or an experienced central vision loss (or to evaluate the results of a surgical intervention or for the possible need for surgical intervention) is dictated by stage of disease or degree of risk factors, just as with glaucoma evaluation.

Those examinations found to have been performed at a frequency greater than is necessary for reasonable medical management of the patient's condition are not covered.

Screening services are not a Medicare benefit.

The use of any device for purposes of providing a medically reasonable and necessary service under this LCD is within the discretion of the individual provider, assuming FDA approval and any other applicable regulatory criteria are met. Thus, reference to specific devices is not a subject of this LCD.
Sources of Information
N/A
Bibliography
  1. American Academy of Ophthalmology. Summary benchmarks for preferred practice pattern® guidelines. AAO PPP Panel, Hoskins Center for Quality Eye Care. 2015;1-11.
  2. Turalba AV, Grosskreutz C. A review of current technology used in evaluating visual function in glaucoma. Seminars in Ophthalmology. 2010;25(5-6):309-316.
    doi: 10.3109/08820538.2010.518898

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
06/29/2023 R15

06/29/2023: Biannual review completed with no change in coverage. Minor grammatical changes made throughout.
  • Other (Review)
10/01/2021 R14

09/30/2021 Grammar and punctuation corrections made throughout the LCD. Relocated references listed under “Sources of Information” to “Bibliography”, and corrected AMA formatting. Review completed 08/20/2021.
  • Other (Review)
10/31/2019 R13

10/31/2019 Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS and ICD-10 codes were been removed from this LCD and placed in Billing and Coding: Visual Fields linked to this LCD.
  • Other
10/01/2019 R12

9/26/2019 ICD-10 description change to codes G43.A0 and G43.A1 in Group 1 table. Review completed.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2018 R11

10/01/2018 ICD-10 Code updates: description change to codes I63.333 and I63.343; deleted codes H57.8 and I63.8; and added codes H57.811, H57.812, H57.813, H57.89, I63.81, I67.850 and I67.858.
  • Revisions Due To ICD-10-CM Code Changes
04/01/2018 R10

04/01/2018 Annual review done 03/07/2018. No change in coverage.
  • Other (Annual Review)
10/01/2017 R9

10/01/2017 ICD-10 code updates: Description changes to Group 1: I63.211, I63.212, I63.22, I63.323, and  I63.333 and Group 2: S04.031A, S04.031D, S04.031S, S04.032A, S04.032D, S04.032S, S04.041A, S04.041D, S04.041S, S04.042A, S04.042D, S04.042S, S04.049A, S04.049D, and S04.049S; deleted codes from Group 1 H54.0, H54.11, H54.12, H54.2, H54.41, H54.42, H54.51, and H54.52; and added codes to Group 1 H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53,
H54.0X54, H54.0X55, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.511A, H54.512A, H54.52A1, and H54.52A2. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
04/01/2017 R8 04/01/2017 Annual review done 03/08/2017. Formatting change made. No change in coverage.
  • Other
01/01/2017 R7 01/01/2017 Per code updates: description change to code 92083, effective 01/01/2017.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R6 10/01/2016 Per ICD-10 Code Updates: in Group 1 deleted codes E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, H34.811, H34.812, H34.813, H34.831, H34.832, H34.833, H35.31, H35.32, H40.11X1, H40.11X2, H40.11X3, H40.11X4, I60.21, and I60.22 and added codes E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E08.37X1, E08.37X2, E08.37X3, 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, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.359, E09.37X1, E09.37X2, E09.37X3, E10.321, E10.329, E09.3591, E09.3592, E09.3593, 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, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E10.37X1, E10.37X2, E10.37X3, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, 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, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E11.37X1, E11.37X2, E11.37X3, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, 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, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.3591, E13.3592, E13.3593, E13.37X1, E13.37X2, E13.37X3, H34.8110, H34.8111, H34.8112, H34.8120, H34.8121, H34.8122, H34.8130, H34.8131, H34.8132, H34.8310, H34.8311, H34.8312, H34.8320, H34.8321, H34.8322, H34.8330, H34.8331, H34.8332, H35.3111, H35.3112, H35.3113, H35.3114, H35.3121, H35.3122, H35.3123, H35.3124, H35.3131, H35.3132, H35.3133, H35.3134, H35.3211, H35.3212, H35.3213, H35.3221, H35.3222, H35.3223, H35.3231, H35.3232, H35.3233, H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133, H40.1134, I60.2, I63.013, I63.033, I63.113, I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, and I63.443, effective 10/01/2016; and in Group 2 deleted codes S06.0X2A, S06.0X3A, S06.0X4A, S06.0X5A, S06.0X6A, effective 10/01/2016.
  • Revisions Due To ICD-10-CM Code Changes
09/01/2016 R5 09/01/2016 Added code Z09 to Group 1 effective 10/01/2015.
  • Reconsideration Request
04/01/2016 R4 04/01/2016 Annual review done 03/03/2016. Formatting changes made. Removed CAC information. Updated Sources of Information. No change in coverage.
  • Other (Annual Review)
10/01/2015 R3 10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8 Notice and corresponding table from the CMS National Coverage Policy section. No other changes to policy or coverage.
  • Other
10/01/2015 R2 05/01/2014: Annual review completed 03/05/2014; duplicate statement removed, no change in coverage.
  • Other
10/01/2015 R1 06/03/2014: ICD-10 codes Z79.52 & Z79.899 were accidently omitted from table one, were reinserted.
  • Other
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A57483 - Billing and Coding: Visual Fields
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
06/22/2023 06/29/2023 - N/A Currently in Effect You are here
09/20/2021 10/01/2021 - 06/28/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

Read the LCD Disclaimer

Submit Feedback/Ask a Question