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Local Coverage Determination (LCD)

Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

L33467

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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
L33467
Original ICD-9 LCD ID
Not Applicable
LCD Title
Ophthalmology: Extended Ophthalmoscopy and Fundus Photography
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 05/11/2023
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

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §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. 

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

42 CFR §410.32(a) 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).

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §80.6 Intraocular Photography

42 CFR §411.15(k)(1) indicates coverage exclusion for any services that are not reasonable and necessary for the following purpose: For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

1. Abstract:

Fundus photography

Fundus photography uses a special camera to photograph structures behind the lens of the eye including the vitreous, retina, choroids, and optic nerve to document and follow disease processes of the eyes.

Extended ophthalmoscopy

Extended ophthalmoscopy is the detailed examination of the retina with a detailed drawing. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may use scleral depression.

It is performed by the physician, when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and always includes a drawing of the retina (macula, fundus, and periphery) large enough to provide sufficient detail to be of use to a clinician who might do a follow-up examination with interpretation and report. The examination must be used for medical decision making.

2. Indications:

Fundus photography

Fundus photography is not covered for routine screening.

In general, fundus photography is considered medically necessary only when it would assist in:

1. Monitoring potential progression of a disease process; or
2. Guidance in evaluating the need for or response to a specific treatment or intervention.

In other words, medical necessity for fundus photography should guide a clinical decision.

Therefore, baseline photos to document a condition that is reasonably expected to be static and/or not require future treatment would not be medically necessary. Such photos to provide a means of comparison to detect, for example, potential progression of diabetic retinopathy, advanced non-neovascular (dry) macular degeneration with “suspicious” areas, or a nevus or other tumor could be medically necessary.

Repeat fundus photography should only be performed at clinically reasonable intervals (i.e., consistent with a noted change on examination or after sufficient time has elapsed for progression or for a treatment to have reasonably had an impact).

Specific to this policy, fundus photography to guide a given treatment or intervention (vs. monitoring for progression) e.g., photos used to guide the placement of macular laser treatment or to monitor the response to intraocular vascular endothelial growth factor (VEGF) agents should only be ordered by the physician who actually performs the treatment or intervention.

Extended ophthalmoscopy

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions (THIS LIST MAY NOT BE EXHAUSTIVE):

a. Malignant neoplasm of the retina or choroid

b. Retained (old) intraocular foreign body, either magnetic or nonmagnetic

c. Retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration

d. Retinal detachment with or without retinal defect-the patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as “a curtain came down over my eyes.”

e. Symptoms suggestive of retinal defect (ex: flashes and/or floaters)

f. Retinal defects without retinal detachment

g. Diabetic retinopathy (i.e., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers-this may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation

h. Sudden visual loss or transient visual loss

i. Chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment

j. Penetrating wound to the orbit resulting in the retention of a foreign body in the eye

k. Blunt injury to the eye or adnexa

l. Disorders of the vitreous body (i.e., vitreous hemorrhage or posterior vitreous detachment)-spots before the eyes (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders

m. Posterior scleritis-signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field

n. Vogt-Koyanagi-Harada syndrome- A condition characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea

o. Degenerative disorders of the globe

p. Retinoschisis and retinal cysts-patients may complain of light flashes and floaters

q. Signs and symptoms of endophthalmitis, which may include severe pain, redness, photophobia, and profound loss of vision

r. Glaucoma or is a glaucoma suspect-this may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve

s. Systemic disorders which may be associated with retinal pathology

t. High axial length myopia

u. Retinal edema

v. Metamorphopsia

w. High-risk medication for retinopathy or optic neuropathy

x. Choroidal nevus being evaluated for malignant transformation

y. Macular degeneration

3. Limitations:

If the study is performed as a screening service, it is not covered by Medicare.

Fundus photography

  • All tests must include a written interpretation. If an interpretation is not included in the same medical record with the photograph, then both the technical and professional components will be considered not medically necessary.
  • Fundus photography of a normal retina will be denied as not medically necessary.

Extended ophthalmoscopy

  • Extended ophthalmoscopy of a fellow eye without signs or symptoms or new abnormalities on general ophthalmoscopic exam will be denied as not medically necessary. Repeated extended ophthalmoscopy at each visit without change in signs, symptoms or condition may be denied as not medically 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

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

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

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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 performance of extended ophthalmoscopy or fundus photography for specific conditions may be performed as often as reasonable and necessary to make clinical decisions in the treatment of the condition. All documentation should be legible, maintained in the patient's medical record and available to the A/B MAC upon request.

Fundus photography

The patient's medical record must contain documentation that fully supports the medical necessity for fundus photography as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

A copy of the fundus photographs must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves. The medical record should also document whether the pupil was dilated for the procedure.

Extended ophthalmoscopy

The patient's medical record must contain documentation that fully supports the medical necessity for extended ophthalmoscopy for each eye, as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Retinal drawings meeting the indicated specifications must be maintained in the patient’s record:

  • All items being documented must be clearly identified and labeled.

  • There must be a separate detailed sketch, with a minimum size of approximately 4 inches in diameter (retina to periphery or optic nerve margin).

  • An extensive scaled drawing must accurately represent normal, abnormal and findings of interest in a given patient such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears or tumors.


Documentation in the patient’s medical record for a diagnosis of glaucoma must include all of the following:

  • Optic nerve abnormalities should be documented in a separate drawing from ANY in the retina, and should meet the above size requirements. For example:
    • cupping, disc rim, pallor and slope
    • any pathology surrounding the optic nerve.


Documentation of the specific method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.

The medical record should document whether the pupil was dilated.

All findings and a plan of action should be documented in the patient's medical record supporting the medical necessity for the test(s).
Sources of Information
N/A
Bibliography

Fundus Photography

American Optometric Association. 2004. Care of the Patient with Age-Related Macular Degeneration. Accessed 3/27/23.

American Optometric Association. 2014. Eye Care of the Patient with Diabetes Mellitus. Accessed 3/27/23.

American Optometric Association. 2004. Care of the Patient with Retinal Detachment and Related Peripheral Vitreoretinal Disease. Accessed 3/27/23.

Armaly MF. Optic cup in normal and glaucomatous eyes. Invest Ophth. 1970;9(6):425-429.

Bakri SJ, Sculley L, Singh AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13.

Mayfield J. Who cares about the quality of diabetes care? Almost everyone! Clin Diabet. 1998; 16(4):161-167.

Singh RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195-208.

Extended Ophthalmoscopy

Bartley GB, Liesegang TJ. Essentials of Ophthalmology. Philadelphia, PA: JB Lippincott Co;1992.

Duane TD, Tasman W, Jaeger EA. Duane’s Clinical Ophthalmology. Vol 3. Philadelphia, PA:JB Lippincott Co;1993.

Ho AC, Guyer DR, Fine SL. Clinical examination of the posterior segment of the eye. Retina-Vitreous Macula. Philadelphia, PA:WB Saunders Co;1999;1:21-28.

Jones WL, Reidy RW. Atlas of the Peripheral Ocular Fundus. Butterworth-Heinemann Publishers;1985:1-4.

McPhee SJ, Papadakis MA, Tierney LM. Current Medical Diagnosis and Treatment. Stamford CT:Appleton and Lange;1996.

Newell FW. Ophthalmology:Principles and Concepts. St. Louis, MO:Mosby;1992.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
05/11/2023 R17

Under CMS National Coverage Policy deleted regulation CMS Manual System, One-Time Notification, Pub. 100-20, Transmittal 477, dated April 24, 2009, Change Request and added 42 CFR §411.15(k)(1) indicates coverage exclusion for any services that are not reasonable and necessary for the following purpose: For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.
  • Provider Education/Guidance
01/01/2021 R16

Under CMS National Coverage Policy deleted regulation Title XVIII of the Social Security Act, §1833(e) and added regulation CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §80.6. Under Bibliography updated broken hyperlinks for sources 1 and 3 and changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

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.

This revision is retroactive effective for dates of services on or after 1/1/2021.
  • Provider Education/Guidance
10/24/2019 R15

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography A53060 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

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.

 
  • Provider Education/Guidance
10/10/2019 R14

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity has been removed and is included in the related Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography A53060 article.

Under CMS National Coverage Policy deleted the verbiage that reads “Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the policy. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:”.

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.
  • Provider Education/Guidance
10/01/2019 R13

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added ICD-10 code Q87.19 and deleted ICD-10 code Q87.1. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

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.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
03/15/2018 R12

Under CMS National Coverage Policy in the first paragraph deleted the second and third sentence. Under Bibliography-Fundus Photography corrected the first three links for the cited practice guidelines including the year the articles were updated, as appropriate. Under Bibliography-Extended Ophthalmoscopy punctuation and spelling were corrected. Author initials and the supplement number were added to the following: Ho AC, Guyer DR, Fine SL. Clinical examination of the posterior segment of the eye. Retina-Vitreous Macula. Philadelphia, PA: WB Saunders Co;1999;1:21-28.

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.
  • Provider Education/Guidance
  • Typographical Error
  • Other
02/26/2018 R11 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R10 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R9

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes H44.2A1, H44.2A2, H44.2A3, H44.2B1, H44.2B2, H44.2B3, H44.2C1, H44.2C2, H44.2C3, H44.2D1, H44.2D2, H44.2D3, H44.2E1, H44.2E2 and H44.2E3. This revision is due to the 2017 Annual ICD-10 Code Updates.

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
03/16/2017 R8 Under Sources of Information and Basis for Decision- Grammatical correction to remove comma from Armaly, MF. Addition of italicized font to journal title and add the published year to “Invest. Ophth. 1970; 9(6): 425-429.” Correction made to title of journal to read “Int Ophthalmol Clin.” Addition of correct pages to journal excerpt “Who cares about the quality…” to include pg 161-67. Grammatical correction to book reference to correct spelling of “Philadelphia, Pa” to read “Philadelphia, PA”. Grammatical correction to publisher Butterworth-Heimann to read correctly, Butterworth-Heinemann. Grammatical correction to year for book, “Duane’s Clinical Ophthalmology”, changed from 1994 to 1993.
  • Provider Education/Guidance
  • Typographical Error
12/15/2016 R7 Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133 and H40.1134. Under Sources of Information and Basis for Decision added Armaly, MF. Optic cup in Normal and glaucomatous eyes. Invest. Ophth.9(6):425-429. These codes are effective on or after October 01, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
  • Reconsideration Request
11/28/2016 R6 Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes H35.3211, H35.3212, H35.3213, H35.3221, H35.3222, H35.3223, H35.3231, H35.3232 and H35.3233 as these codes were inadvertently omitted. These codes are effective on or after October 01, 2016.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2016 R5 Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513, E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539, E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, 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, H35.3110, H35.3111, H35.3112, H35.3113, H35.3114, H35.3120, H35.3121, H35.3122, H35.3123, H35.3124, H35.3130, H35.3131, H35.3132, H35.3133, H35.3134, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E13.37X1, E13.37X2, E13.37X3 and E13.37X9. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes deleted ICD-10 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 and H40.11X4. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/1/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
02/19/2016 R4 This LCD was consolidated into an A/B MAC LCD. The Part A Ophthalmology: Extended Ophthalmoscopy and Fundus Photography LCD L34571 is being retired effective 02/19/2016 as this LCD is being incorporated into LCD L33467. No substantive changes were made to the active LCD.

Under Associated Contractor Numbers added 11201, 11301, 11401, and 11501. Under CMS National Coverage Policy corrected the citation for Change Request 6338. Under Bill Type Codes the bill types were deleted as per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. Under Associated Information-Documentation Requirements deleted “a” in the first sentence of the first paragraph. Under Sources of Information and Basis for Decision corrected the spelling of ophthalmology throughout this section and added punctuation. Under Sources of Information and Basis for Decision-Fundus Photography corrected the publication date for Age-Related Macular Degeneration, corrected the title cited to now read Care of the Patient with Retinal Detachment and Related Peripheral Vitreoretinal Disease, corrected the spelling of the author name Singh, and the following citation was placed in the AMA citation format: Mayfield J. Who cares about the quality of diabetes care? Almost Everyone! Clin Diabet. 1998;16(4):161. Under Sources of Information and Basis for Decision-Extended Ophthalmoscopy added author initials, added the author name TD Duane, corrected the spelling of “peripheral” in the third cited source and corrected the spelling of “Stamford” in the fourth cited source.
  • Provider Education/Guidance
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Typographical Error
10/01/2015 R3 Under Coverage Indications, Limitations and/or Medical Necessity sub-heading 1. Abstract, Fundus Photography, the last sentence in that paragraph "This procedure does not include laser scanning of the retina." was removed as it does not reflect the current technology used to perform fundus photography.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity in the Abstract Fundus photography section added clarification to the first sentence … to document and follow disease processes of the eyes. In the indications Fundus Photography section under the CPT code 92227 corrected the sentence to read …cause retinal disease when the test is ordered by the treating physician. Also made some grammatical and punctuation corrections to this section.
Under Associated Information in Documentation Requirements added all documentation should be legible, maintained in the patient’s record and available to the A/B MAC upon request.
Under Sources of information and Basis for Decision corrected all sources to AMA formatting and updated hyperlinks to sources on the web.
  • Provider Education/Guidance
  • Other (Annual Validation)
10/01/2015 R1 Under ICD-10 Codes That Support Medical Necessity section of the LCD a descriptor change was made to the following ICD-10 Codes due to the CMS Quarterly Update in June 2014:M08.88 and M12.08.
Descriptor changes were made per CMS Quarterly Update in June 2014.
These description changes became effective 7/1/2014.


To view this future effective LCD, go to the LCDs and NCDs Web page under the Medical Policies section of the J11 Part A Web site. Choose your appropriate state, choose active LCDs, future LCDs, and then the title of the LCD you wish to view. The LCDs are listed in alphabetical order.
  • Revisions Due To ICD-10-CM Code Changes
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Updated On Effective Dates Status
05/01/2023 05/11/2023 - N/A Currently in Effect You are here
03/09/2021 01/01/2021 - 05/10/2023 Superseded View
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