SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Electroretinography (ERG)

A58706

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Source Article ID
N/A
Article ID
A58706
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Electroretinography (ERG)
Article Type
Billing and Coding
Original Effective Date
01/30/2022
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement 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.

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

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. 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.
  3. 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
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
92273 ELECTRORETINOGRAPHY (ERG), WITH INTERPRETATION AND REPORT; FULL FIELD (IE, FFERG, FLASH ERG, GANZFELD ERG)
92274 ELECTRORETINOGRAPHY (ERG), WITH INTERPRETATION AND REPORT; MULTIFOCAL (MFERG)
0509T ELECTRORETINOGRAPHY (ERG) WITH INTERPRETATION AND REPORT, PATTERN (PERG)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(556 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 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
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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L38992 - Electroretinography (ERG)
Related National Coverage Documents
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Updated On Effective Dates Status
11/08/2023 11/16/2023 - N/A Currently in Effect View
09/13/2023 10/01/2023 - 11/15/2023 Superseded View
01/25/2023 01/30/2022 - 09/30/2023 Superseded View
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