Local Coverage Determination (LCD)

Visual Field Examination

L33766

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09101 - MAC A	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09201 - MAC A	J - N	Puerto Rico Virgin Islands
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

LCD Information

Document Information

LCD ID
L33766

LCD Title
Visual Field Examination

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 01/08/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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.

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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

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Visual Field Examination. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Visual Field Examination and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

CMS IOM Publication 100-02, Medicare Benefit Policy Manual,

Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS IOM Publication 100-08, Medicare Program Integrity Manual,

Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions and Part 410.33 Independent diagnostic testing facility.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

History/Background and/or General Information

The visual field is the area within which objects may be seen when the eye is fixed. To standardize testing, several automated and computerized perimeters are available. However, manual perimeters are also utilized.

Covered Indications

VISUAL FIELD EXAMINATIONs will be considered medically reasonable and necessary under any of the following conditions:

The patient has inflammation or disorders of the eyelids potentially affecting the visual field.
The patient has a documented diagnosis of glaucoma.

Please note: stabilization or progression of glaucoma can be monitored only by a visual field examination, and the frequency of such examinations is dependent on the variability of intraocular pressure measurements (e.g., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve.

The patient is a glaucoma suspect as evidenced by an increase in intraocular pressure, asymmetric intraocular measurements of greater than 2-3 mm Hg between the two eyes, or has optic nerves suspicious for glaucoma which may be manifested as asymmetrical cupping, disc hemorrhage, or an absent or thinned temporal rim.
The patient has a documented disorder of the optic nerve, the neurologic visual pathway, or retina.

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

The patient has had a recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.
The patient has a recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia, or giant cell arteritis.
The patient is having an initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital ptosis.
The patient has inflammation or disorders of the orbit, potentially affecting the visual field.
The patient has sustained a significant eye injury.
The patient has an unexplained visual loss which may be described as “trouble seeing” or “vision going in and out”.
The patient has a pale or swollen optic nerve documented by a visual exam of recent origin.
The patient is having some new functional limitations which may be due to visual field loss (e.g., reports by family that patient is running into things).
The patient is being evaluated initially for macular degeneration or has experienced central vision loss resulting in vision measured at or below 20/70.

Please note: repeated examinations for a diagnosis of macular degeneration or an experienced central vision loss are not necessary unless changes in vision are documented or to evaluate the results of a surgical intervention.

The patient is receiving or has completed treatment of a high-risk medication that may cause visual side effects (e.g., a patient on plaquenil may develop retinopathy).

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
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ICD-10-CM Codes that Support Medical Necessity

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

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Visual Field Examination (A57637) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Visual Field Examination (A57637) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options, Inc. reference LCD number(s) – L29038, L29308, L29487

American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. (2003). Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco, CA. Retrieved October 24, 2005.

American Optometric Association. (2002). Care of the patient with diabetes mellitus (3rd ed.). St. Louis, MO. Retrieved October 24, 2005.

American Optometric Association. (2002). Care of the patient with open angle glaucoma (2nd ed.). St. Louis, MO. Retrieved October 24, 2005.

Bibliography

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
01/08/2019	R9	Revision Number: 7 Publication: November 2019 Connection LCR A/B2019-075 Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act, Code of Federal Regulations, and IOM references were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 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 LCD.	Other (Revision based on CR 10901)
10/01/2018	R8	Revision Number: 6 Publication: September 2018 Connection LCR A/B2018-074 Explanation of Revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised. Deleted ICD-10-CM diagnosis code H57.8. Added ICD-10-CM diagnosis code range H57.811 - H57.89. In addition, new diagnosis codes were added within existing diagnosis code ranges. The effective date of this revision is based on date of service. 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 LCD.	Revisions Due To ICD-10-CM Code Changes
10/01/2017	R7	Revision Number: 5 Publication: September 2017 Connection LCR A/B2017-038 Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Descriptor revised for ICD-10-CM diagnosis code S04.031A, S04.039S, S04.041A, S04.049S. Added ICD-10-CM diagnosis codes H44.2A1-H44.2E9, H54.0X33-H54.0X55, H54.1131-H54.1225, H54.2X11-H54.2X22, H54.413A-H54.415A, H54.42A3-H54.42A5, H54.511A-H54.512A, H54.52A1-H54.52A2. Deleted ICD-10-CM diagnosis codes H54.0, H54.2, H54.41, H54.42, H54.51, H54.52. The effective date of this revision is based on date of service. 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.	Revisions Due To ICD-10-CM Code Changes
01/01/2017	R6	11/16/2016 Annual 2017 HCPCS Update (CR9752). For CPT/HCPCS codes 92083, either the short description and/or the long description was changed.	Revisions Due To CPT/HCPCS Code Changes
10/01/2016	R5	Revision Number: 4 Publication: October 2016 Connection LCR A/B2016-097 Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Revised ICD-10 code range E08.311-E08.36 to read E08.311-E08.37X9, and code range E09.311-E09.36 to read E09.311-E09.37X9. The effective date of this revision is based on date of service.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R4	Revision Number: 3 Publication: January 2016 Connection LCR A/B2015-037 Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis code range H35.51-H35.54 to the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is for claims processed on or after 12/28/15, for dates of service on or after 10/01/15.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R3	Revision Number: 2 Publication: November 2015 Connection LCR A/B2015-026 Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes E10.39, E11.39, E13.39, Z09, Z79.3, Z79.891, and Z79.899 to the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is for claims processed on or after 11/12/15, for dates of service on or after 10/01/15.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R2	Revision Number: 1 Publication: October 2015 Connection LCR A/B2015-016 Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes H40.001-H40.009 H40.011,H40.012,H40.013,H40.021,H40.022,H40.023,H40.031,H40.032,H40.033,H40.041,H40.042 H40.043,H40.051,H40.052,H40.053,H40.061,H40.062, and H40.063 to the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is based on date of service.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.	Provider Education/Guidance

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A57637 - Billing and Coding: Visual Field Examination

Updated On	Effective Dates	Status
11/21/2019	01/08/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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Visual Field Examination

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Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

Additional ICD-10 Information

General Information

Revision History Information

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