SUPERSEDED Local Coverage Determination (LCD)

Visual Fields Testing

L34394

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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.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34394
Original ICD-9 LCD ID
Not Applicable
LCD Title
Visual Fields Testing
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 10/06/2022
Revision Ending Date
10/04/2023
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

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 Section 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.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Decisions Manual, Chapter 1:

    80.9 Computer Enhanced Perimetry.

CMS Transmittal No. 1770, Publication 100 – 04, Medicare Claims Processing Manual, Change Request #6520, July 10, 2009, Medicare contractor annual update of the international classification of diseases, ninth revision, clinical modification (ICD-9-CM).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Visual field testing detects defects in the field of vision, testing the function of the retina, optic nerve and optic pathways. Formal visual field tests are generally performed using automated perimetry, i.e., measurement of the ability to see points of light at varying locations on a curved surface.

Indications:

Visual field examinations are considered medically necessary for the conditions listed below:

  1. The patient has a disorder of the eyelid(s) potentially affecting the visual field(s).
  2. The patient has a visual field defect detected on gross visual field testing (e.g., confrontational testing).
  3. The patient has a documented diagnosis of glaucoma.
    It should be noted that the progression of, and effects of treatment on glaucoma can be monitored only through periodic visual field testing. The frequency of such examinations is dependent on changes in intraocular pressure (IOP), retinal damage and changes at the optic disc.
  4. The patient is suspected of having glaucoma; signs include increased intraocular pressure, asymmetric IOP measurements, notching or thinning of the neuroretinal rim, splinter hemorrhages and asymmetric appearance of the discs.
  5. The patient has a documented disorder of the optic nerve, the retina or the neurologic visual pathway.
  6. The patient has a recent intracranial hemorrhage, an intracranial mass or a recent increased intracranial pressure measurement (with or without visual symptoms).
  7. The patient has a recent occlusion / stenosis of cerebral or precerebral arteries.
  8. The patient has a history of a cerebral aneurysm, pituitary or occipital tumor potentially affecting the visual fields.
  9. The patient is being evaluated for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.
  10. The patient has a disorder of the orbit potentially affecting the visual field.
  11. The patient has sustained a significant eye injury.
  12. The patient has unexplained visual loss.
  13. The patient has a pale or swollen optic nerve on a recent examination.
  14. The patient is having new functional limitations which may be due to visual field loss (e.g., reports by family of patient bumping into objects). (change to e.g.,)
  15. The patient is taking a medication with a high risk of affecting the visual system (e.g., Plaquenil).
  16. The patient is being evaluated for macular degeneration, or has experienced central vision loss (< 20/70). (Repeated examinations for diagnosis of macular degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to evaluate the results of a surgical intervention).

Limitations:

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

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

Summary of Evidence

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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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators is not responsible for the continuing viability of Web site addresses listed below.

Mansbereger S. Shaban D. Early detection of glaucomatous visual field loss: why, what, where, and how. Ophthalmol Clin North Am. 2005;18(3):365–373.

Noble J, Greene HL, Levinson W, et al, eds. Textbook of Primary Care Medicine. 3rd ed. St Louis, MO: Mosby; 2001.

Other contractors’ LCDs.

Yanoff M, Duker JS. Ophthalmology. 2nd ed. St. Louis, MO: Mosby; 2004.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/06/2022 R14

R12

Revision Effective: 10/06/2022

Revision Explanation: Annual Review, no changes made

09/26/2022: 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.

  • Other (Annual Review)
09/30/2021 R13

R11

Revision Effective: 09/30/2021

Revision Explanation: Annual Review, no changes made

09/22/2021: 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.

  • Other (Annual Review)
09/26/2019 R12

R10

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made

09/15/2020: 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.

  • Other (Annual Review)
09/26/2019 R11

R9

Revision Effective: 09/26/2019

Revision Explanation: Annual Review, no changes made

09/26/2019: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.

  • Other (Annual Review, no changes made)
09/19/2019 R10

R8

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019: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.

  • Revisions Due To Code Removal
09/19/2019 R9

R7

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019: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.

  • Revisions Due To Code Removal
10/01/2018 R8

R6

Revision Effective: 8-15-2019

Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901.

08/5/2019-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.

  • Other (Removed billing and coding based on CR10901)
10/01/2018 R7

Revision#: R5
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

09/27/2018-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.

  • Other (Annual Review)
10/01/2018 R6

Revision#: R7
Revision Effective: 10/01/2018
Revision Explanation: During annual ICD-10 update codes I63.8 was deleted and replaced with I63.81 and I63.89. The following new codes were added during the annual update: H02.881, H02.882, H02.884, H02.885, H02.88A, H02.88B, I67.850, and I67.858.

09/24/2018-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.

 

 

R6
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R5

Revision#: R5
Revision Effective: 10/01/2017
Revision Explanation: During annual ICD-10 update codes H54.0, H54.11, H54.12, H54.2, H54.41, H54.42, H54.51, and H54.52 were deleted and replaced with 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. New codes E11.10, E11.11, and F41.0 were also added from ICD-10 annual update.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R4 Revision#: R4
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
10/01/2015 R3 Revision#: R3
Revision Effective: 10/01/2016
Revision Explanation: During ICd-10 annual update 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-H34.813, H34.831-H34.833, H35.31, H35.32, H40.11X0-H40.11X4, I60.21, and I60.22 were deleted. The replacement code and description fro I60.21 and I60.22 was not added as CGS feels this is not a good fit for the policy. The following codes were added due to the annual update: E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, 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, E09.3591, e09.3592, E09.3593, E09.37X1, E09.37X2, E09.37X3, 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, H31.8121, 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 , H35.3222 , H35.3231, H35.3232, H35.3233, H40.1110, H40.1111, H40.1112, H40.1113, H40.1114, H40.1120, H40.1121, H40.1122, H40.1123, H40.1124, H40.1130, H40.1131, H40.1132, H40.1133, H40.1134
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 Revison#: R1
2Effective: 10/01/2015
Revision Explanation: Annual Review no changes made.
  • Other (Annual Review)
10/01/2015 R1 Revison#: R1
Revision Effective: 10/01/2015
Revision Explanation: Accepted 2015 HCPCS description change 92083.
  • Revisions Due To CPT/HCPCS Code Changes
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
09/29/2023 10/05/2023 - N/A Currently in Effect View
09/26/2022 10/06/2022 - 10/04/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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