Local Coverage Determination (LCD)

Visual Fields Testing

L33574

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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
L33574
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 09/19/2019
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
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 Determinations (NCD) Manual, Chapter 1:

    80.9 Computer Enhanced Perimetry.

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). 
  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.

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
View 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
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services 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
09/19/2019 R12

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R11

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56551. There has been no change in coverage with this LCD revision.

 

  • Provider Education/Guidance
10/01/2018 R10

Due to the annual ICD-10-CM diagnosis code update, code I63.8 has been deleted from the "ICD-10 Codes that Support Medical Necessity" section- Group 1.

DATE (10/01/2018): 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.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R9

 

Due to the annual ICD-10-CM update, the following ICD-10 codes were deleted from the ICD-10 Codes that Support Medical Necessity section:

H54.0 was deleted from Group 1 and replaced by H54.0X33- H54.0X35; H54.0X43- H54.0X45; H54.0X53- H54.0X55; H54.11 was deleted from Group 1 and replaced by H54.1131- H54.1132, H54.1141- H54.1142; H54.1151- H54.1152; H54.12 was deleted from Group 1 and replaced by H54.1213- H54.1215; H54.1223- H54.1225; H54.2 was deleted from Group 1 and replaced by H54.2X11- H54.2X12; H54.2X21- H54.2X22; H54.41 was deleted from Group 1 and replaced by H54.413A - H54.415A; H54.42 was deleted from Group 1 and replaced by H54.42A3- H54.42A5; H54.51 was deleted from Group 1 and replaced by H54.511A - H54.512A ; H54.52 was deleted from Group 1 and replaced by H54.52A1- H54.52A2, effective for services rendered on or after 10/1/2017.

Due to the annual ICD-10-CM update, the following ICD-10 codes and code ranges were added to the ICD-10 Codes that Support Medical Necessity section effective for services rendered on or after 10/1/2017: H44.2A1- H44.2A3; H44.2B1- H44.2B3; H44.2C1- H44.2C3; H44.2D1- H44.2D3; H44.2E1- H44.2E3; S04.039S; S04.041A, S04.041D, S04.041S, S04.042A, S04.042D, S04.042S, S04.049A, S04.049D, S04.049S.

DATE (10/01/2017): 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
01/01/2017 R8 Added ICD-10-CM diagnosis code H35.3122 to the ICD-10-CM codes that support medical necessity section, effective for services rendered on or after 10/01/2016.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2017 R7 Based on the CPT/HCPCS annual update, the description for 92083- Group 1 has been changed.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R6 Added ICD-10-CM diagnosis code H35.3114 and diagnosis code ranges H35.3120-H35.3124 and H35.3130-H35.3134 to the ICD-10 Codes that Support Medical Necessity section due to annual ICD-10-CM update.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R5 The ICD-10 Codes that Support Medical Necessity section was updated due to the annual ICD-10-CM diagnosis codes update.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R4 Added ICD-10-CM diagnosis code H53.40 to the ICD-10-CM codes that support medical necessity section, effective for services rendered on or after 10/01/2015.
  • Request for Coverage by a Practitioner (Part B)
01/01/2016 R3 Based on 2016 HCPS updates, the description was changed for CPT code 92083.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 Bill type codes added
  • Provider Education/Guidance
10/01/2015 R1 Added ICD-10-CM diagnosis code range to the ICD-10-CM diagnosis codes that support medical necessity section:S04.011A through S04.12XS.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56551 - Billing and Coding: Visual Fields Testing
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/11/2019 09/19/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • visual fields
  • eyes
  • ophthalmology
  • vision

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