LCD for Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (L25466)


Contractor Information

 
Contractor Name 
National Government Services, Inc.
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


LCD Information

 
LCD ID Number 
L25466 
 
LCD Title 
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 
 
Contractor's Determination Number 
L25466 (R6) 
 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  
 
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
 
 
Primary Geographic Jurisdiction
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
 
Oversight Region
Region I, II, III, V
 
 
Original Determination Effective Date 
For services performed on or after 12/01/2007  
 
Original Determination Ending Date 
 
 
Revision Effective Date 
For services performed on or after 01/01/2011  
 
Revision Ending Date 
 
 
Indications and Limitations of Coverage and/or Medical Necessity 
Abstract:

Fundus photography
Fundus photography involves the use of a retinal camera to document abnormalities of of the retina and disease processes affecting the eye, in order to follow the progress of such disease. The test must be used in the medical decision making for the patient.

Extended ophthalmoscopy
Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy. The examination must be used in the medical decision making for the patient.

Indications:

Fundus photography
Fundus photography may be indicated to document abnormalities of disease processes affecting the eye, or to follow the progress of such disease.

In order to document a disease process or follow the progress of a disease, photographs and an interpretation and report of the test may be necessary. Photographs and an interpretation and report of the test may also be necessary to plan treatment for a disease process.

Fundus photography may be used for the diagnosis of conditions such as macular degeneration, retinal neoplasms, choroid disturbances and diabetic retinopathy, glaucoma, multiple sclerosis or other central nervous system anomalies.

Fundus photography may be indicated for examination of the retina in diabetic patients, in whom symptoms of visual disturbances may be present and in whom retinal examination may be unremarkable or normal.

Extended ophthalmoscopy
Extended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy.

An extended ophthalmoscopy may be considered medically reasonable and necessary for the following conditions:
  • Malignant neoplasm of the retina or choroid.

  • Retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her eye (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing.

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

  • 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."

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

  • Retinal defects without retinal detachment.

  • 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.

  • Experienced sudden visual loss or transient visual loss.

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

  • Sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the eye.

  • Sustained a blunt injury to the eye or pariorbita.

  • 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.

  • 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.

  • Vogt-Koyanagi 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.

  • Degenerative disorders of the globe.

  • Retinoschisis and retinal cysts. Patients may complain of light flashes and floaters.

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

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

  • Systemic disorders which may be associated with retinal pathology.

  • High axial length myopia

  • Retinal edema

  • Metamorphopsia

  • High-risk medication for retinopathy or optic neuropathy.

  • Choroidal nevus being evaluated for malignant transformation.

  • Macular degeneration.
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 (CPT codes 92250 and 92228) are bilateral services on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee.
  • Fundus photography is not a substitute for an annual dilated examination by a qualified professional (e.g., in diabetic patients). Fundus photographs taken by a non-eye professional and sent (transtelephonically, via internet, or by other means) to a qualified professional for interpretation are covered for the monitoring and management of active retinal disease. The interpretation of tests done with remote imaging must be performed by a physician or qualified non-physician practitioner.
  • Remote imaging for detection of retinal disease (CPT code 92227) is considered screening and will be denied as non-covered.
  • Provision of fundus photography, by providers other than opthalmologists or optometrists, as a screening test to facilitate referral to a specialist is contrary to requirements for testing as codified in 42CFR 410.32, and is therefore not covered. Furthermore, the ordering/performance of fundus photography by eye specialists prior to a face-to-face encounter is similarly not covered or reimbursable.
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.
  • General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination (92002-92004) and are not separately payable, but these should still be documented in the patient's medical record.
  • If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated in the attached Appendix A, the service is not separately payable and will be considered part of a general ophthalmologic exam (92002-92014) or E&M service.
  • Extended ophthalmoscopy (codes 92225, 92226) performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed.
  • If the medical record does not include the interpretation and report, the extended ophthalmoscopy will be denied as not medically necessary.
  • Extended ophthalmoscopy will be denied as not medically necessary when it is done in lieu of routine ophthalmoscopy unless the indication for this more extensive examination is documented in the medical record.
  • When other ophthalmological tests (e.g., fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical expectation that the multiple imaging services might provide additive (non-duplicative) information.
Other Comments:

For claims submitted to the fiscal intermediary or Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.

Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

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 dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services. 
 


Coding Information

 
Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
 
 
Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

0409 Other Imaging Services - Other Imaging Services
0450 Emergency Room - General Classification
051X Clinic - General Classification
052X Free-Standing Clinic - General Classification
0962 Professional Fees - Ophthalmology
 
 
CPT/HCPCS Codes 

92225 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; INITIAL
92226 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; SUBSEQUENT
92227 REMOTE IMAGING FOR DETECTION OF RETINAL DISEASE (EG, RETINOPATHY IN A PATIENT WITH DIABETES) WITH ANALYSIS AND REPORT UNDER PHYSICIAN SUPERVISION, UNILATERAL OR BILATERAL
92228 REMOTE IMAGING FOR MONITORING AND MANAGEMENT OF ACTIVE RETINAL DISEASE (EG, DIABETIC RETINOPATHY) WITH PHYSICIAN REVIEW, INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL
92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT
 
 
ICD-9 Codes that Support Medical Necessity 
ICD-9-CM codes for fundus photography and extended ophthalmoscopy (CPT codes 92225, 92226, 92228, 92250)
115.02 HISTOPLASMA CAPSULATUM RETINITIS
115.12 HISTOPLASMA DUBOISII RETINITIS
115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED
130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS
190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID
190.5 MALIGNANT NEOPLASM OF RETINA
190.6 MALIGNANT NEOPLASM OF CHOROID
224.5 BENIGN NEOPLASM OF RETINA
224.6 BENIGN NEOPLASM OF CHOROID
225.1 BENIGN NEOPLASM OF CRANIAL NERVES
249.50 SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.51 SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS, UNCONTROLLED
250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.51 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.52 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.53 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
360.00 PURULENT ENDOPHTHALMITIS UNSPECIFIED
360.01 ACUTE ENDOPHTHALMITIS
360.02 PANOPHTHALMITIS
360.03 CHRONIC ENDOPHTHALMITIS
360.04 VITREOUS ABSCESS
360.11 SYMPATHETIC UVEITIS
360.12 PANUVEITIS
360.13 PARASITIC ENDOPHTHALMITIS UNSPECIFIED
360.14 OPHTHALMIA NODOSA
360.19 OTHER ENDOPHTHALMITIS
360.20 DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED
360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA
360.23 SIDEROSIS OF GLOBE
360.24 OTHER METALLOSIS OF GLOBE
360.29 OTHER DEGENERATIVE DISORDERS OF GLOBE
360.30 HYPOTONY OF EYE UNSPECIFIED
360.31 PRIMARY HYPOTONY OF EYE
360.32 OCULAR FISTULA CAUSING HYPOTONY
360.33 HYPOTONY ASSOCIATED WITH OTHER OCULAR DISORDERS
360.34 FLAT ANTERIOR CHAMBER OF EYE
360.40 DEGENERATED GLOBE OR EYE UNSPECIFIED
360.41 BLIND HYPOTENSIVE EYE
360.42 BLIND HYPERTENSIVE EYE
360.43 HEMOPHTHALMOS EXCEPT CURRENT INJURY
360.44 LEUCOCORIA
360.50 FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED
360.51 FOREIGN BODY MAGNETIC IN ANTERIOR CHAMBER OF EYE
360.52 FOREIGN BODY MAGNETIC IN IRIS OR CILIARY BODY
360.53 FOREIGN BODY MAGNETIC IN LENS
360.54 FOREIGN BODY MAGNETIC IN VITREOUS
360.55 FOREIGN BODY MAGNETIC IN POSTERIOR WALL
360.59 INTRAOCULAR FOREIGN BODY MAGNETIC IN OTHER OR MULTIPLE SITES
360.60 FOREIGN BODY INTRAOCULAR UNSPECIFIED
360.61 FOREIGN BODY IN ANTERIOR CHAMBER
360.62 FOREIGN BODY IN IRIS OR CILIARY BODY
360.63 FOREIGN BODY IN LENS
360.64 FOREIGN BODY IN VITREOUS
360.65 FOREIGN BODY IN POSTERIOR WALL OF EYE
360.69 INTRAOCULAR FOREIGN BODY IN OTHER OR MULTIPLE SITES
360.81 LUXATION OF GLOBE
360.89 OTHER DISORDERS OF GLOBE
361.00 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED
361.01 RECENT RETINAL DETACH PARTIAL WITH SINGLE DEFECT
361.02 RECENT RETINAL DETACH PARTIAL WITH MULTIPLE DEFECTS
361.03 RECENT RETINAL DETACH PARTIAL WITH GIANT TEAR
361.04 RECENT RETINAL DETACH PARTIAL WITH RETINAL DIALYSIS
361.05 RECENT RETINAL DETACH TOTAL OR SUBTOTAL
361.06 OLD RETINAL DETACH PARTIAL
361.07 OLD RETINAL DETACH TOTAL OR SUBTOTAL
361.10 RETINOSCHISIS UNSPECIFIED
361.11 FLAT RETINOSCHISIS
361.12 BULLOUS RETINOSCHISIS
361.13 PRIMARY RETINAL CYSTS
361.14 SECONDARY RETINAL CYSTS
361.19 OTHER RETINOSCHISIS AND RETINAL CYSTS
361.2 SEROUS RETINAL DETACH
361.30 RETINAL DEFECT UNSPECIFIED
361.31 ROUND HOLE OF RETINA WITHOUT DETACH
361.32 HORSESHOE TEAR OF RETINA WITHOUT DETACH
361.33 MULTIPLE DEFECTS OF RETINA WITHOUT DETACH
361.81 TRACTION DETACH OF RETINA
361.89 OTHER FORMS OF RETINAL DETACH
361.9 UNSPECIFIED RETINAL DETACH
362.01 BACKGROUND DIABETIC RETINOPATHY
362.02 PROLIFERATIVE DIABETIC RETINOPATHY
362.03 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS
362.04 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY
362.05 MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY
362.06 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY
362.07 DIABETIC MACULAR EDEMA
362.10 BACKGROUND RETINOPATHY UNSPECIFIED
362.11 HYPERTENSIVE RETINOPATHY
362.12 EXUDATIVE RETINOPATHY
362.13 CHANGES IN VASCULAR APPEARANCE OF RETINA
362.14 RETINAL MICROANEURYSMS NOS
362.15 RETINAL TELANGIECTASIA
362.16 RETINAL NEOVASCULARIZATION NOS
362.17 OTHER INTRARETINAL MICROVASCULAR ABNORMALITIES
362.18 RETINAL VASCULITIS
362.20 RETINOPATHY OF PREMATURITY, UNSPECIFIED
362.21 RETROLENTAL FIBROPLASIA
362.22 RETINOPATHY OF PREMATURITY, STAGE 0
362.23 RETINOPATHY OF PREMATURITY, STAGE 1
362.24 RETINOPATHY OF PREMATURITY, STAGE 2
362.25 RETINOPATHY OF PREMATURITY, STAGE 3
362.26 RETINOPATHY OF PREMATURITY, STAGE 4
362.27 RETINOPATHY OF PREMATURITY, STAGE 5
362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY
362.30 RETINAL VASCULAR OCCLUSION UNSPECIFIED
362.31 CENTRAL RETINAL ARTERY OCCLUSION
362.32 RETINAL ARTERIAL BRANCH OCCLUSION
362.33 PARTIAL RETINAL ARTERIAL OCCLUSION
362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION
362.35 CENTRAL RETINAL VEIN OCCLUSION
362.36 VENOUS TRIBUTARY (BRANCH) OCCLUSION OF RETINA
362.37 VENOUS ENGORGEMENT OF RETINA
362.40 RETINAL LAYER SEPARATION UNSPECIFIED
362.41 CENTRAL SEROUS RETINOPATHY
362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM
362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM
362.50 MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED
362.51 NONEXUDATIVE SENILE MACULAR DEGENERATION OF RETINA
362.52 EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA
362.53 CYSTOID MACULAR DEGENERATION OF RETINA
362.54 MACULAR CYST HOLE OR PSEUDOHOLE OF RETINA
362.55 TOXIC MACULOPATHY OF RETINA
362.56 MACULAR PUCKERING OF RETINA
362.57 DRUSEN (DEGENERATIVE) OF RETINA
362.60 PERIPHERAL RETINAL DEGENERATION UNSPECIFIED
362.61 PAVING STONE DEGENERATION OF RETINA
362.62 MICROCYSTOID DEGENERATION OF RETINA
362.63 LATTICE DEGENERATION OF RETINA
362.64 SENILE RETICULAR DEGENERATION OF RETINA
362.65 SECONDARY PIGMENTARY DEGENERATION OF RETINA
362.66 SECONDARY VITREORETINAL DEGENERATIONS
362.70 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED
362.71 RETINAL DYSTROPHY IN SYSTEMIC OR CEREBRORETINAL LIPIDOSES
362.72 RETINAL DYSTROPHY IN OTHER SYSTEMIC DISORDERS AND SYNDROMES
362.73 VITREORETINAL DYSTROPHIES
362.74 PIGMENTARY RETINAL DYSTROPHY
362.75 OTHER DYSTROPHIES PRIMARILY INVOLVING THE SENSORY RETINA
362.76 DYSTROPHIES PRIMARILY INVOLVING THE RETINAL PIGMENT EPITHELIUM
362.77 RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE
362.81 RETINAL HEMORRHAGE
362.82 RETINAL EXUDATES AND DEPOSITS
362.83 RETINAL EDEMA
362.84 RETINAL ISCHEMIA
362.85 RETINAL NERVE FIBER BUNDLE DEFECTS
362.89 OTHER RETINAL DISORDERS
363.00 FOCAL CHORIORETINITIS UNSPECIFIED
363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY
363.03 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE
363.04 FOCAL CHOROIDITIS AND CHORIORETINITIS PERIPHERAL
363.05 FOCAL RETINITIS AND RETINOCHOROIDITIS JUXTAPAPILLARY
363.06 FOCAL RETINITIS AND RETINOCHOROIDITIS MACULAR OR PARAMACULAR
363.07 FOCAL RETINITIS AND RETINOCHOROIDITIS OF OTHER POSTERIOR POLE
363.08 FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL
363.10 DISSEMINATED CHORIORETINITIS UNSPECIFIED
363.11 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS POSTERIOR POLE
363.12 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS PERIPHERAL
363.13 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS GENERALIZED
363.14 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS METASTATIC
363.15 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY
363.20 CHORIORETINITIS UNSPECIFIED
363.21 PARS PLANITIS
363.22 HARADA'S DISEASE
363.30 CHORIORETINAL SCAR UNSPECIFIED
363.31 SOLAR RETINOPATHY
363.32 OTHER MACULAR SCARS OF RETINA
363.33 OTHER SCARS OF POSTERIOR POLE OF RETINA
363.34 PERIPHERAL SCARS OF RETINA
363.35 DISSEMINATED SCARS OF RETINA
363.40 CHOROIDAL DEGENERATION UNSPECIFIED
363.41 SENILE ATROPHY OF CHOROID
363.42 DIFFUSE SECONDARY ATROPHY OF CHOROID
363.43 ANGIOID STREAKS OF CHOROID
363.50 HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED
363.51 CIRCUMPAPILLARY DYSTROPHY OF CHOROID PARTIAL
363.52 CIRCUMPAPILLARY DYSTROPHY OF CHOROID TOTAL
363.53 CENTRAL DYSTROPHY OF CHOROID PARTIAL
363.54 CENTRAL CHOROIDAL ATROPHY TOTAL
363.55 CHOROIDEREMIA
363.56 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID PARTIAL
363.57 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL
363.61 CHOROIDAL HEMORRHAGE UNSPECIFIED
363.62 EXPULSIVE CHOROIDAL HEMORRHAGE
363.63 CHOROIDAL RUPTURE
363.70 CHOROIDAL DETACH UNSPECIFIED
363.71 SEROUS CHOROIDAL DETACH
363.72 HEMORRHAGIC CHOROIDAL DETACH
363.8 OTHER DISORDERS OF CHOROID
363.9 UNSPECIFIED DISORDER OF CHOROID
364.22 GLAUCOMATOCYCLITIC CRISES
364.24 VOGT-KOYANAGI SYNDROME
364.3 UNSPECIFIED IRIDOCYCLITIS
364.82 PLATEAU IRIS SYNDROME
365.00 PREGLAUCOMA UNSPECIFIED
365.01 OPEN ANGLE WITH BORDERLINE GLAUCOMA FINDINGS
365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA
365.03 STEROID RESPONDERS BORDERLINE GLAUCOMA
365.04 OCULAR HYPERTENSION
365.10 OPEN-ANGLE GLAUCOMA UNSPECIFIED
365.11 PRIMARY OPEN ANGLE GLAUCOMA
365.12 LOW TENSION OPEN-ANGLE GLAUCOMA
365.13 PIGMENTARY OPEN-ANGLE GLAUCOMA
365.14 GLAUCOMA OF CHILDHOOD
365.15 RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA
365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED
365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA
365.22 ACUTE ANGLE-CLOSURE GLAUCOMA
365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA
365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA
365.31 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE
365.32 CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE
365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES
365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS
365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT ANOMALIES
365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES
365.51 PHACOLYTIC GLAUCOMA
365.52 PSEUDOEXFOLIATION GLAUCOMA
365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS
365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER
365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK
365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS
365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE
365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS
365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA
365.81 HYPERSECRETION GLAUCOMA
365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE
365.83 AQUEOUS MISDIRECTION
365.89 OTHER SPECIFIED GLAUCOMA
365.9 UNSPECIFIED GLAUCOMA
368.11 SUDDEN VISUAL LOSS
368.12 TRANSIENT VISUAL LOSS
368.13 VISUAL DISCOMFORT
368.14 VISUAL DISTORTIONS OF SHAPE AND SIZE
368.15 OTHER VISUAL DISTORTIONS AND ENTOPTIC PHENOMENA
368.16 PSYCHOPHYSICAL VISUAL DISTURBANCES
368.40 VISUAL FIELD DEFECT UNSPECIFIED
368.41 SCOTOMA INVOLVING CENTRAL AREA
368.42 SCOTOMA OF BLIND SPOT AREA
368.43 SECTOR OR ARCUATE VISUAL FIELD DEFECTS
368.44 OTHER LOCALIZED VISUAL FIELD DEFECT
368.45 GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION
368.8 OTHER SPECIFIED VISUAL DISTURBANCES
368.9 UNSPECIFIED VISUAL DISTURBANCE
377.00 PAPILLEDEMA UNSPECIFIED
377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE
377.02 PAPILLEDEMA ASSOCIATED WITH DECREASED OCULAR PRESSURE
377.03 PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER
377.04 FOSTER-KENNEDY SYNDROME
377.10 OPTIC ATROPHY UNSPECIFIED
377.11 PRIMARY OPTIC ATROPHY
377.12 POSTINFLAMMATORY OPTIC ATROPHY
377.13 OPTIC ATROPHY ASSOCIATED WITH RETINAL DYSTROPHIES
377.14 GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC
377.15 PARTIAL OPTIC ATROPHY
377.16 HEREDITARY OPTIC ATROPHY
377.21 DRUSEN OF OPTIC DISC
377.22 CRATER-LIKE HOLES OF OPTIC DISC
377.23 COLOBOMA OF OPTIC DISC
377.24 PSEUDOPAPILLEDEMA
377.30 OPTIC NEURITIS UNSPECIFIED
377.31 OPTIC PAPILLITIS
377.32 RETROBULBAR NEURITIS (ACUTE)
377.33 NUTRITIONAL OPTIC NEUROPATHY
377.34 TOXIC OPTIC NEUROPATHY
377.39 OTHER OPTIC NEURITIS
377.41 ISCHEMIC OPTIC NEUROPATHY
377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS
377.49 OTHER DISORDERS OF OPTIC NERVE
377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS
377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS
377.53 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS
377.54 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS
379.07 POSTERIOR SCLERITIS
379.21 VITREOUS DEGENERATION
379.22 CRYSTALLINE DEPOSITS IN VITREOUS
379.23 VITREOUS HEMORRHAGE
379.24 OTHER VITREOUS OPACITIES
379.25 VITREOUS MEMBRANES AND STRANDS
379.26 VITREOUS PROLAPSE
379.29 OTHER DISORDERS OF VITREOUS
379.32 SUBLUXATION OF LENS
379.34 POSTERIOR DISLOCATION OF LENS
714.0 RHEUMATOID ARTHRITIS
714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.32 PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS
714.33 MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS
743.51 VITREOUS ANOMALIES CONGENITAL
743.52 FUNDUS COLOBOMA
743.53 CHORIORETINAL DEGENERATION CONGENITAL
743.54 CONGENITAL FOLDS AND CYSTS OF POSTERIOR SEGMENT
743.55 CONGENITAL MACULAR CHANGES
743.56 OTHER RETINAL CHANGES CONGENITAL
743.57 SPECIFIED CONGENITAL ANOMALIES OF OPTIC DISC
743.58 VASCULAR ANOMALIES CONGENITAL
743.59 OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT
759.5 TUBEROUS SCLEROSIS
759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED
759.82 MARFAN SYNDROME
871.5 PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY
871.6 PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED
Additional ICD-9-CM codes for extended ophthalmoscopy (CPT codes 92225, 92226)
198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
237.70 NEUROFIBROMATOSIS UNSPECIFIED
237.71 NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE
237.72 NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS
249.00 SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.01 SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, UNCONTROLLED
249.10 SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.11 SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, UNCONTROLLED
249.20 SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.21 SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, UNCONTROLLED
249.30 SECONDARY DIABETES MELLITUS WITH OTHER COMA, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.31 SECONDARY DIABETES MELLITUS WITH OTHER COMA, UNCONTROLLED
249.40 SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.41 SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, UNCONTROLLED
249.60 SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.61 SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, UNCONTROLLED
249.70 SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.71 SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, UNCONTROLLED
249.80 SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.81 SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, UNCONTROLLED
249.90 SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.91 SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED
250.00 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.01 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.02 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.03 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED
250.10 DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.11 DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.12 DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.13 DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED
250.20 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.21 DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.22 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.23 DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED
250.30 DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.31 DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.32 DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.33 DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED
250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.41 DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
250.42 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.43 DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
360.9 UNSPECIFIED DISORDER OF GLOBE
364.00 ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED
364.01 PRIMARY IRIDOCYCLITIS
364.02 RECURRENT IRIDOCYCLITIS
364.03 SECONDARY IRIDOCYCLITIS INFECTIOUS
364.04 SECONDARY IRIDOCYCLITIS NONINFECTIOUS
364.10 CHRONIC IRIDOCYCLITIS UNSPECIFIED
364.11 CHRONIC IRIDOCYCLITIS IN DISEASES CLASSIFIED ELSEWHERE
364.21 FUCHS' HETEROCHROMIC CYCLITIS
364.23 LENS-INDUCED IRIDOCYCLITIS
364.41 HYPHEMA OF IRIS AND CILIARY BODY
364.42 RUBEOSIS IRIDIS
364.51 ESSENTIAL OR PROGRESSIVE IRIS ATROPHY
364.52 IRIDOSCHISIS
364.53 PIGMENTARY IRIS DEGENERATION
364.54 DEGENERATION OF PUPILLARY MARGIN
364.55 MIOTIC CYSTS OF PUPILLARY MARGIN
364.56 DEGENERATIVE CHANGES OF CHAMBER ANGLE
364.57 DEGENERATIVE CHANGES OF CILIARY BODY
364.59 OTHER IRIS ATROPHY
364.60 IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY
364.61 IMPLANTATION CYSTS OF IRIS AND CILIARY BODY
364.62 EXUDATIVE CYSTS OF IRIS OR ANTERIOR CHAMBER
364.63 PRIMARY CYST OF PARS PLANA
364.64 EXUDATIVE CYST OF PARS PLANA
364.70 ADHESIONS OF IRIS UNSPECIFIED
364.71 POSTERIOR SYNECHIAE OF IRIS
364.72 ANTERIOR SYNECHIAE OF IRIS
364.73 GONIOSYNECHIAE
364.74 ADHESIONS AND DISRUPTIONS OF PUPILLARY MEMBRANES
364.75 PUPILLARY ABNORMALITIES
364.76 IRIDODIALYSIS
364.77 RECESSION OF CHAMBER ANGLE OF EYE
364.81 FLOPPY IRIS SYNDROME
364.89 OTHER DISORDERS OF IRIS AND CILIARY BODY
364.9 UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY
368.46 HOMONYMOUS BILATERAL FIELD DEFECTS
368.47 HETERONYMOUS BILATERAL FIELD DEFECTS
368.60 NIGHT BLINDNESS UNSPECIFIED
368.61 CONGENITAL NIGHT BLINDNESS
368.62 ACQUIRED NIGHT BLINDNESS
368.63 ABNORMAL DARK ADAPTATION CURVE
368.69 OTHER NIGHT BLINDNESS
376.40 DEFORMITY OF ORBIT UNSPECIFIED
376.41 HYPERTELORISM OF ORBIT
376.42 EXOSTOSIS OF ORBIT
376.43 LOCAL DEFORMITIES OF ORBIT DUE TO BONE DISEASE
376.44 ORBITAL DEFORMITIES ASSOCIATED WITH CRANIOFACIAL DEFORMITIES
376.45 ATROPHY OF ORBIT
376.46 ENLARGEMENT OF ORBIT
376.47 DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY
376.50 ENOPHTHALMOS UNSPECIFIED AS TO CAUSE
376.51 ENOPHTHALMOS DUE TO ATROPHY OF ORBITAL TISSUE
376.52 ENOPHTHALMOS DUE TO TRAUMA OR SURGERY
376.6 RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT
871.7 UNSPECIFIED OCULAR PENETRATION
871.9 UNSPECIFIED OPEN WOUND OF EYEBALL
921.3 CONTUSION OF EYEBALL
958.1 FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA
995.50 UNSPECIFIED CHILD ABUSE
995.51 CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE
995.52 CHILD NEGLECT (NUTRITIONAL)
995.53 CHILD SEXUAL ABUSE
995.54 CHILD PHYSICAL ABUSE
995.55 SHAKEN BABY SYNDROME
995.59 OTHER CHILD ABUSE AND NEGLECT
Additional ICD-9-CM codes for fundus photography (CPT codes 92228, 92250)
042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
094.85 SYPHILITIC RETROBULBAR NEURITIS
115.01 HISTOPLASMA CAPSULATUM MENINGITIS
115.12 HISTOPLASMA DUBOISII RETINITIS
115.90 HISTOPLASMOSIS UNSPECIFIED WITHOUT MANIFESTATION
115.91 HISTOPLASMOSIS MENINGITIS UNSPECIFIED
115.93 HISTOPLASMOSIS PERICARDITIS UNSPECIFIED
115.94 HISTOPLASMOSIS ENDOCARDITIS
115.95 HISTOPLASMOSIS PNEUMONIA UNSPECIFIED
115.99 HISTOPLASMOSIS UNSPECIFIED WITH OTHER MANIFESTATION
130.1 CONJUNCTIVITIS DUE TO TOXOPLASMOSIS
190.1 MALIGNANT NEOPLASM OF ORBIT
190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND
190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA
190.4 MALIGNANT NEOPLASM OF CORNEA
190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT
190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE
190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED
198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
224.0 BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID
234.0 CARCINOMA IN SITU OF EYE
238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES
239.81* NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID
239.89* NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES
270.2 OTHER DISTURBANCES OF AROMATIC AMINO-ACID METABOLISM
282.60 SICKLE-CELL DISEASE UNSPECIFIED
282.61 HB-SS DISEASE WITHOUT CRISIS
282.62 HB-SS DISEASE WITH CRISIS
282.63 SICKLE-CELL/HB-C DISEASE WITHOUT CRISIS
282.64 SICKLE-CELL/HB C DISEASE WITH CRISIS
282.68 OTHER SICKLE-CELL DISEASE WITHOUT CRISIS
282.69 OTHER SICKLE-CELL DISEASE WITH CRISIS
340 MULTIPLE SCLEROSIS
362.9 UNSPECIFIED RETINAL DISORDER
368.51 PROTAN DEFECT
368.52 DEUTAN DEFECT
368.53 TRITAN DEFECT
368.54 ACHROMATOPSIA
368.55 ACQUIRED COLOR VISION DEFICIENCIES
368.59 OTHER COLOR VISION DEFICIENCIES
377.43 OPTIC NERVE HYPOPLASIA
377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS
377.62 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS
377.63 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH INFLAMMATORY DISORDERS
377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS
377.72 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS
377.73 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH INFLAMMATORY DISORDERS
377.75 CORTICAL BLINDNESS
377.9 UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS
379.00 SCLERITIS UNSPECIFIED
379.09 OTHER SCLERITIS
379.11 SCLERAL ECTASIA
695.4 LUPUS ERYTHEMATOSUS
710.0 SYSTEMIC LUPUS ERYTHEMATOSUS
714.1 FELTY'S SYNDROME
714.2 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
714.4 CHRONIC POSTRHEUMATIC ARTHROPATHY
714.81 RHEUMATOID LUNG
714.89 OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES
714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY
759.81 PRADER-WILLI SYNDROME
759.83 FRAGILE X SYNDROME
759.89 OTHER SPECIFIED CONGENITAL ANOMALIES
771.0 CONGENITAL RUBELLA
794.11 NONSPECIFIC ABNORMAL RETINAL FUNCTION STUDIES
794.12 NONSPECIFIC ABNORMAL ELECTRO-OCULOGRAM (EOG)
794.13 NONSPECIFIC ABNORMAL VISUALLY EVOKED POTENTIAL
794.14 NONSPECIFIC ABNORMAL OCULOMOTOR STUDIES
961.4 POISONING BY ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA
995.54 CHILD PHYSICAL ABUSE
995.55 SHAKEN BABY SYNDROME
995.59 OTHER CHILD ABUSE AND NEGLECT
*For dates of service prior to October 1, 2009, ICD-9 code 239.8 is in effect. On or after October 1, 2009, ICD-9 codes 239.81 and 239.89 replace 239.8.
 
 
Diagnoses that Support Medical Necessity 
Not applicable 
 
ICD-9 Codes that DO NOT Support Medical Necessity 
Not applicable
 
 
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 
 
 
Diagnoses that DO NOT Support Medical Necessity 
Not applicable 


General Information

 
Documentation Requirements 
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. (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.

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 document whether the pupil was dilated, and which drug was used.

Documentation supporting the medical necessity should be legible, maintained in the patient's record, and must be available to the carrier upon request.

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. (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.

Retinal drawings meeting the specifications indicated in the attached Appendix A of this policy must be maintained in the patient's record.
  • There must be a separate detailed sketch, minimal size of 3-4 inches.
  • All items noted must be identified and labeled.
  • Drawings in four (4) - six (6) standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.
  • Optic nerve abnormalities should be separately drawn.
  • An extensive scaled drawing must accurately represent normal, abnormal and common findings 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 (ICD-9-CM codes 365.00-365.9) must include all of the following:
  • A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment,
  • Documentation of cupping, disc rim, pallor, and slope,
  • Documentation of any surrounding pathology around the optic nerve.
Documentation specific to the 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, and which drug was used.

All findings and a plan of action should be documented in notes.

Although routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, these should still be documented in the patient's medical record.

Documentation supporting the medical necessity should be legible, maintained in the patient's record, and must be available to the carrier upon request. 
 
Appendices 
See attachment 
 
Utilization Guidelines 
Patients actively being treated with intravitreal injections of medication for exudative AMD (ICD-9-CM code 362.52) may require up to 12 extended ophthalmoscopies per eye, per year.

Conditions coded with other ICD-9-CM codes in the range 360.0-365.9, may require up to six (6) extended ophthalmoscopic examinations per eye, per year.

For ICD-9-CM codes 190.0, 190.5, 190.6, 198.89, 224.5 and 224.6, up to four (4) extended ophthalmoscopic examinations may be required per eye, per year.

Other conditions usually require no more than two (2) extended ophthalmoscopic examinations per eye, per year.

Extended ophthalmoscopy is a physician service (examination of the eye) commonly occurring during the global post-operative period of ophthalmic surgery. As a physician service, it is included in the aftercare of the patient and is not separately billable.

Fundus photography is usually medically necessary no more than two times per year.

Fundus photography of a normal retina will be considered not medically necessary.

Services exceeding these parameters will be considered not medically necessary. 
 
Sources of Information and Basis for Decision 
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.

Fundus photography

Bakri SJ, Sculley L, Sing AD. Imaging techniques for uveal melanoma. Int Ophthalmol Clin. 2006;46(1):1-13. Available at
http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Mayfeild J. Who cares about the quality of diabetes care? Almost everyone! Clinical Diabetes. 1998;16(4). Available at http://journal.diabetes.org/clinicaldiabetes/v16n41998/Mayfield.htm. Accessed July 21, 2006.

National Guideline Clearinghouse. Age-related macular degeneration. Limited revision. www.guideline.gov. Accessed July 21, 2006.

National Guideline Clearinghouse. Care of the patient with diabetes mellitus. 3rd edition. www.guideline.gov. Accessed July 21, 2006.

National Guideline Clearinghouse. Care of the patient with retinal detachment and related peripheral vitreoretinal disease. Available at: www.guideline.gov. Accessed July 21, 2006.

Other carrier policy (Empire Medical Services [effective 06/01/1996] L682). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed July 21, 2006.

Other carrier policy (Empire Medical Services [effective 10/01/2005] L3634 R5). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed July 21, 2006.

Other carrier policy (First Coast Service Options [effective 10/30/2006] L18148 R1). Available at: http://www.cms.hhs.gov/mcd/results.asp?show=all&t=200647152649 . Accessed December 8, 2006.

Singh RP, Young LH. Diagnostic tests for posterior segment inflammation. Int Ophthalmol Clin. 2006;46(2):195-208. Available at http://gateway.ut.ovid.com.proxy.medlib.iupui.edu/qw2/ovidweb.cgi. Accessed November 15, 2006.

Extended ophthalmoscopy

Carrier Medical Director, BCBS, Kansas.

Comments from American Academy of Ophthalmology.

Comments from New York State Ophthalmology CAC representative.

Comments from New York State Optometric Association.

Comments from practicing ophthalmologists.

Comments from retinal consultants.

Consultants in Optometry (New Jersey).

CPT editorial staff.

Duane's Clinical Ophthalmology, J. B. Lippincott Co.; 1994.

Essentials of Ophthalmology, Editors Bartley and Liesegang, J.B. Lippincott Co.;1992.

Focus panel of invited ophthalmologists/optometrists convened October 11, 2000 in New York.

Guyer DR, Yannuzzi LA, Chang, S, Shields JA, Green WR. Retina vitreous macula, clinical examination of the posterior segment of the eye. W.B. Saunders Company; 1999:21-28.

HCFA Regional Office reimbursement specialist.

Jones WL, Reidy RW. Atlas of the peripheral ocular fundus. Butterworth Publishers; 1985:1-4.

McPhee S,Papadakis M, Tierney L. Current medical diagnosis and treatment. Stanford: Appleton and Lange; 1996.

Newell F. Ophthalmology-principles and concepts. St. Louis: Mosby; 1992.

Other Carrier Policies:
First Coast Service Options, Inc. - Florida – Database # L6030 (12/18/1995)
Trailblazer Health Enterprises, LLC – Texas – Database # L8867 (11/05/1996)

Additional sources used in reconsideration request for September 1, 2009 revision:

Bresnick GH, Mukaamel DB, Dickinson JC, Cole DR. A screening approach to the surveillance of patients with diabetes for the presence of vision-threatening retinopathy. Ophthalmology. 2000;107:19-24.

Hutchinson A, McIntosh A, Peters J, et al. Effectiveness of screening and monitoring tests for diabetic retinopathy – a systemic review. Diabetes Medicine. 2000;17:495-506.

Personal communications, CMS Coverage and Analysis Group, Marcel Salive, MD, Louis Jacques, MD and Ross Brechner, MD.

Williams GA, Scott IU, Haller JA, et al. Single-field fundus photography for diabetic retinopathy screening. Ophthalmology. 2004;111:1055-1062. 
 
Advisory Committee Meeting Notes 
Carrier Advisory Committee Meeting Date(s):

06/13/2007 - NewYork/New Jersey
06/25/2007 – Indiana
06/28/2007 - Kentucky

This coverage determination does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this determination is developed in consultation with representatives from Advisory Committee members and/or from various state and local provider organizations.

Any Carrier Advisory Committee (CAC) related information, including Start Date and End Date of Comment Period, reflects the last time this LCD passed through the Comment and Notice process. Formal comment is not required for LCDs being adopted as part of the MAC transition. 
 
Start Date of Comment Period 
06/01/2007 
 
End Date of Comment Period 
07/16/2007 
 
Start Date of Notice Period 
01/01/2011 
 
Revision History Number 
R6 
 
Revision History Explanation 
R6 (effective 01/01/2011): LCD revised for annual HCPCS updates. CPT code 92227 added as non-covered (screening) and CPT code 92228 added under coverage criteria for fundus photography. Minor template changes made. No comment or notice periods required and none given.

R5 (effective 04/01/2010): Bill type instructions for reporting FQHC services updated to add bill type 77X. Minor template changes made. No comment or notice periods required and none given.

R4 (Effective 09/01/2009): Source of revision – Reconsideration request. ICD-9 codes 368.11-368.16, 368.40-368.45, 368.8 and 368.9 moved from list of payable diagnoses for extended ophthalmoscopy to list of payable diagnoses for extended ophthalmoscopy AND fundus photography; Indications section updated with addititional coverage criteria related to fundus photography for diabetic patients; Limitations section updated with additional criteria on fundus photography used for screening; Sources of Information updated with sources used in reconsideration request.

Based on annual ICD-9 updates, effective for dates of service on or after October 1, 2009, ICD-9 code 239.8 is replaced by codes 239.81 and 239.89 as payable for fundus photography. No comment and notice periods required and none given.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this LCD as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

R3(Effective 03/01/2009): Source of revision – Internal. Abstract expanded; minor formatting changes made.

05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this LCD as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

11/14/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00308 is removed from this LCD. Effective on this date, claims processing for Delaware is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state, and the claims processing for New York and Connecticut is performed by National Government Services under the J-13 MAC contract; carrier number 00805 is removed, and claims processing for New Jersey is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state.

11/01/2008: Corrected version of policy published 10/01/2008 with no change in the revision effective date of 10/01/2008. ICD-9-CM code 362.29 was omitted in error from ICD-9-CM codes for Fundus Photography and Extended Ophthalmoscopy.

R2(Effective 10/01/2008): Source of revision – Internal: Annual ICD-9-CM update: added codes 249.50, 249.51, 362.20, 362.22-362.27, and 362.82 as payable for CPT codes 92225, 92226 and 92250; added codes 249.00, 249.01, 249.10, 249.11, 249.20, 249.21, 249.30, 249.31, 249.40, 249.41, 249.60, 249.61, 249.70, 249.71, 249.80, 249.81, 249.90, and 249.91 as payable for CPT codes 92225 and 92226.

08/18/2008 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00454 was removed from this LCD as the claims processing for American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands was transitioned to Palmetto GBA, the Part A/Part B MAC contractor in these states.

R1: This revised LCD is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut – Part B the LCD is effective on August 1, 2008; for Upstate New York – Part B, the LCD is effective on September 1, 2008; and for New York and Connecticut – Part A, the LCD is effective on November 14, 2008. For New York – Part A (contract 00308), the content of this LCD is currently in effect but the LCD will be transferred to the J-13 contract number 13201 on November 14, 2008.

This LCD was revised to add the Jurisdiction 13 (J-13) MAC contractor numbers.

The CMS Statement of Work for the J13 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This NGS policy is being promulgated to the J13 MAC as the most clinically appropriate LCD within that jurisdiction.

The NGS roster of LCDs has been developed under the combined experience of seven Medicare contractor medical directors. The criteria for inclusion in this roster includes areas of identified CERT errors, especially repetitive errors; high volume/high dollar/pervasive problems; patient safety issues; potential for automation; beneficiary access to new technology; implementation of NCD; narrative medical necessity parameters for medical review and provider education; and CMS/law enforcement mandates.

NGS LCDs have undergone an advice and comment process from the providers in 23 states. This advice and comment process, the most comprehensive among all Medicare contractors, has ensured that NGS policies have benefited from the most in-depth and scientifically rigorous scrutiny. The NGS policy development process has resulted in the most clinically appropriate LCDs for providers and Medicare beneficiaries.

3/7/2010 - The description for Bill Type Code 73 was changed

8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 73 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0409 was changed
8/1/2010 - The description for Revenue code 0450 was changed
8/1/2010 - The description for Revenue code 0510 was changed
8/1/2010 - The description for Revenue code 0511 was changed
8/1/2010 - The description for Revenue code 0512 was changed
8/1/2010 - The description for Revenue code 0513 was changed
8/1/2010 - The description for Revenue code 0514 was changed
8/1/2010 - The description for Revenue code 0515 was changed
8/1/2010 - The description for Revenue code 0516 was changed
8/1/2010 - The description for Revenue code 0517 was changed
8/1/2010 - The description for Revenue code 0519 was changed
8/1/2010 - The description for Revenue code 0520 was changed
8/1/2010 - The description for Revenue code 0521 was changed
8/1/2010 - The description for Revenue code 0522 was changed
8/1/2010 - The description for Revenue code 0523 was changed
8/1/2010 - The description for Revenue code 0524 was changed
8/1/2010 - The description for Revenue code 0525 was changed
8/1/2010 - The description for Revenue code 0526 was changed
8/1/2010 - The description for Revenue code 0527 was changed
8/1/2010 - The description for Revenue code 0528 was changed
8/1/2010 - The description for Revenue code 0529 was changed
8/1/2010 - The description for Revenue code 0962 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
92225 descriptor was changed in Group 1
92226 descriptor was changed in Group 1 
 
Reason for Change 
HCPCS Addition/Deletion
 
Last Reviewed On Date 
01/01/2011 
 
Related Documents 
Article(s)
A44439 - Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) – Supplemental Instructions Article
 
LCD Attachments 
Appendix A (43,598 bytes)
Ophthalmology: Posterior Sement Imaging (Extended Ophthalmoscopy and Fundus Photography) - Comment and Response (157,688 bytes)