Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27545
LCD Title
Visual Fields
Contractor’s Determination Number
L27545
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 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
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.
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after 08/01/2008
Revision Ending Date
08/31/2008
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Visual field testing is a process to determine defects in the field of vision and tests the function of the retina, optic nerve and optic pathways. Visual field testing may be kinetic or static. In kinetic testing (i.e., Goldmann or tangent screen), the stimulus is moved to different areas and the point at which it is first seen by the patient is marked. In static (stationary) perimetry, a specific point is chosen for examination and the stimulus is increased until its threshold is determined. More complex studies with sophisticated equipments, automated and computerized machines, can accomplish this type of visual examination.
Indications
Medicare will consider reimbursement for a visual field examination for the evaluation and/or treatment of abnormal ophthalmologic or neurological signs, and/or symptoms, and/or known ophthalmologic disease or injuries. Specifically, visual field examinations will be considered medically necessary when the patient has any of the following conditions:
- disorder of the eyelids potentially affecting the visual field;
- documented diagnosis of advanced glaucoma.
Note: The 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 (i.e., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve. Please see LCD: Scanning Computerized Opthalmic Diagnostic Imaging for additional information.
- glaucoma is suspected as evidenced by an increase in intraocular pressure, asymmetric intraocular measurements of greater than 2 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.
- presence of a documented disorder of the optic nerve, the neurological visual pathway, or retina.
- recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.
- recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia or giant cell arteritis.
- history of a cerebral aneurysm, pituitary tumor, occipital tumor or other condition potentially affecting the visual fields.
- a visual field defect demonstrated by gross visual field testing (e.g., confrontation testing).
- as part of an initial workup for bupthalmos, congenital anomalies of the posterior segment or congenital ptosis.
- disorder of the orbit, potentially affecting the visual field.
- significant eye injury was recently sustained.
- an unexplained visual loss, which may be described as “trouble seeing or vision going in and out”.
- a pale or swollen optic nerve documented by a recent examination.
- new functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things).
- use of a medication (e.g., Plaquenil) which has a high risk of potentially affecting the visual system.
- initial evaluation for macular degeneration or has experienced central vision loss resulting in vision measured at or below 20/70.
Note: Repeated examinations for 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
Limitations
Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological service and should not be reported separately.
Coverage Topic
Diagnostic Tests and X-Rays
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.
999x | Not Applicable |
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.
99999 | Not Applicable |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
92081 | VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT) |
92082 | VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR SEMIQUANTITATIVE, AUTOMATED SUPRATHRESHOLD SCREENING PROGRAM, HUMPHREY SUPRATHRESHOLD AUTOMATIC DIAGNOSTIC TEST, OCTOPUS PROGRAM 33) |
92083 | VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND STATIC DETERMINATION WITHIN THE CENTRAL 30¡, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G-1, 32 OR 42, HUMPHREY VISUAL FIELD ANALYZER FULL THRESHOLD PROGRAMS 30-2, 24-2, OR 30/60-2) |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
SYPHILITIC ENCEPHALITIS - OTHER SPECIFIED NEUROSYPHILIS | |
095.8 | OTHER SPECIFIED FORMS OF LATE SYMPTOMATIC SYPHILIS |
136.1 | BEHCET'S SYNDROME |
MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED | |
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE | |
192.0 | MALIGNANT NEOPLASM OF CRANIAL NERVES |
192.1 | MALIGNANT NEOPLASM OF CEREBRAL MENINGES |
MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT - MALIGNANT NEOPLASM OF PINEAL GLAND | |
198.4 | SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM |
BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - BENIGN NEOPLASM OF EYE PART UNSPECIFIED | |
225.0 | BENIGN NEOPLASM OF BRAIN |
225.1 | BENIGN NEOPLASM OF CRANIAL NERVES |
225.2 | BENIGN NEOPLASM OF CEREBRAL MENINGES |
BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT - BENIGN NEOPLASM OF PINEAL GLAND | |
HEMANGIOMA OF INTRACRANIAL STRUCTURES - HEMANGIOMA OF RETINA | |
234.0 | CARCINOMA IN SITU OF EYE |
237.0 | NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
237.1 | NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND |
237.6 | NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES |
237.70 | NEUROFIBROMATOSIS UNSPECIFIED |
237.71 | NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE |
239.6 | NEOPLASM OF UNSPECIFIED NATURE OF BRAIN |
239.7 | NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM |
239.8 | NEOPLASM OF UNSPECIFIED NATURE OF OTHER SPECIFIED SITES |
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC DIFFUSE GOITER WITH THYROTOXIC CRISIS OR STORM | |
TOXIC UNINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC UNINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM | |
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 |
ACROMEGALY AND GIGANTISM - PITUITARY DWARFISM | |
253.5 | DIABETES INSIPIDUS |
253.6 | OTHER DISORDERS OF NEUROHYPOPHYSIS |
253.7 | IATROGENIC PITUITARY DISORDERS |
253.8 | OTHER DISORDERS OF THE PITUITARY AND OTHER SYNDROMES OF DIENCEPHALOHYPOPHYSEAL ORIGIN |
253.9 | UNSPECIFIED DISORDER OF THE PITUITARY GLAND AND ITS HYPOTHALAMIC CONTROL |
259.8 | OTHER SPECIFIED ENDOCRINE DISORDERS |
VITAMIN A DEFICIENCY WITH CONJUNCTIVAL XEROSIS - UNSPECIFIED VITAMIN A DEFICIENCY | |
300.00 | ANXIETY STATE UNSPECIFIED |
300.11 | CONVERSION DISORDER |
310.2 | POSTCONCUSSION SYNDROME |
HEMOPHILUS MENINGITIS - MENINGITIS IN OTHER BACTERIAL DISEASES CLASSIFIED ELSEWHERE | |
ANAEROBIC MENINGITIS - MENINGITIS DUE TO OTHER SPECIFIED BACTERIA | |
320.9 | MENINGITIS DUE TO UNSPECIFIED BACTERIUM |
CRYPTOCOCCAL MENINGITIS - MENINGITIS DUE TO OTHER NONBACTERIAL ORGANISMS CLASSIFIED ELSEWHERE | |
NONPYOGENIC MENINGITIS - MENINGITIS UNSPECIFIED | |
323.01 | ENCEPHALITIS AND ENCEPHALOMYELITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE |
323.02 | MYELITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE |
323.1 | ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS IN RICKETTSIAL DISEASES CLASSIFIED ELSEWHERE |
323.2 | ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS IN PROTOZOAL DISEASES CLASSIFIED ELSEWHERE |
323.41 | OTHER ENCEPHALITIS AND ENCEPHALOMYELITIS DUE TO INFECTION CLASSIFIED ELSEWHERE |
323.42 | OTHER MYELITIS DUE TO INFECTION CLASSIFIED ELSEWHERE |
323.51 | ENCEPHALITIS AND ENCEPHALOMYELITIS FOLLOWING IMMUNIZATION PROCEDURES |
323.52 | MYELITIS FOLLOWING IMMUNIZATION PROCEDURES |
323.61 | INFECTIOUS ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM) |
323.62 | OTHER POSTINFECTIOUS ENCEPHALITIS AND ENCEPHALOMYELITIS |
323.63 | POSTINFECTIOUS MYELITIS |
323.71 | TOXIC ENCEPHALITIS AND ENCEPHALOMYELITIS |
323.72 | TOXIC MYELITIS |
323.81 | OTHER CAUSES OF ENCEPHALITIS AND ENCEPHALOMYELITIS |
323.82 | OTHER CAUSES OF MYELITIS |
323.9 | UNSPECIFIED CAUSES OF ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS |
324.0 | INTRACRANIAL ABSCESS |
331.0 | ALZHEIMER'S DISEASE |
333.81 | BLEPHAROSPASM |
340 | MULTIPLE SCLEROSIS |
341.0 | NEUROMYELITIS OPTICA |
341.1 | SCHILDER'S DISEASE |
341.20 | ACUTE (TRANSVERSE) MYELITIS NOS |
341.21 | ACUTE (TRANSVERSE) MYELITIS IN CONDITIONS CLASSIFIED ELSEWHERE |
341.22 | IDIOPATHIC TRANSVERSE MYELITIS |
341.8 | OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM |
341.9 | DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED |
FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE | |
SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE | |
UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE | |
343.1 | CONGENITAL HEMIPLEGIA |
GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY | |
345.2 | PETIT MAL STATUS EPILEPTIC |
345.3 | GRAND MAL STATUS EPILEPTIC |
LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY - LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES, WITH INTRACTABLE EPILEPSY | |
INFANTILE SPASMS WITHOUT INTRACTABLE EPILEPSY - INFANTILE SPASMS WITH INTRACTABLE EPILEPSY | |
EPILEPSIA PARTIALIS CONTINUA WITHOUT INTRACTABLE EPILEPSY - EPILEPSIA PARTIALIS CONTINUA WITH INTRACTABLE EPILEPSY | |
OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY - OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITH INTRACTABLE EPILEPSY | |
EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY | |
CLASSICAL MIGRAINE WITHOUT INTRACTABLE MIGRAINE - CLASSICAL MIGRAINE WITH INTRACTABLE MIGRAINE SO STATED | |
COMMON MIGRAINE WITHOUT INTRACTABLE MIGRAINE - COMMON MIGRAINE WITH INTRACTABLE MIGRAINE SO STATED | |
VARIANTS OF MIGRAINE WITHOUT INTRACTABLE MIGRAINE - VARIANTS OF MIGRAINE WITH INTRACTABLE MIGRAINE SO STATED | |
OTHER FORMS OF MIGRAINE WITHOUT INTRACTABLE MIGRAINE - OTHER FORMS OF MIGRAINE WITH INTRACTABLE MIGRAINE SO STATED | |
MIGRAINE UNSPECIFIED WITHOUT INTRACTABLE MIGRAINE - MIGRAINE UNSPECIFIED WITH INTRACTABLE MIGRAINE SO STATED | |
348.2 | BENIGN INTRACRANIAL HYPERTENSION |
348.30 | ENCEPHALOPATHY UNSPECIFIED |
348.31 | METABOLIC ENCEPHALOPATHY |
348.39 | OTHER ENCEPHALOPATHY |
348.4 | COMPRESSION OF BRAIN |
360.23 | SIDEROSIS OF GLOBE |
360.29 | OTHER DEGENERATIVE DISORDERS OF GLOBE |
RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL | |
RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS | |
361.2 | SEROUS RETINAL DETACH |
RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH | |
TRACTION DETACH OF RETINA - OTHER FORMS OF RETINAL DETACH | |
361.9 | UNSPECIFIED RETINAL DETACH |
362.01 | BACKGROUND 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 |
BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS | |
362.21 | RETROLENTAL FIBROPLASIA |
362.29 | OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY |
RETINAL VASCULAR OCCLUSION UNSPECIFIED - CENTRAL RETINAL VEIN OCCLUSION | |
RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM | |
MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA | |
PERIPHERAL RETINAL DEGENERATION UNSPECIFIED - SECONDARY VITREORETINAL DEGENERATIONS | |
HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE | |
RETINAL HEMORRHAGE - OTHER RETINAL DISORDERS | |
362.9 | UNSPECIFIED RETINAL DISORDER |
FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL | |
DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY | |
CHORIORETINITIS UNSPECIFIED - HARADA'S DISEASE | |
CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA | |
CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID | |
HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL | |
CHOROIDAL HEMORRHAGE UNSPECIFIED - CHOROIDAL RUPTURE | |
CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH | |
OTHER DISORDERS OF CHOROID - UNSPECIFIED DISORDER OF CHOROID | |
364.22 | GLAUCOMATOCYCLITIC CRISES |
PREGLAUCOMA UNSPECIFIED - OCULAR HYPERTENSION | |
OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA | |
PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA | |
CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE - CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE | |
GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES | |
PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS | |
GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA | |
HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA | |
365.9 | UNSPECIFIED GLAUCOMA |
AMBLYOPIA UNSPECIFIED - REFRACTIVE AMBLYOPIA | |
SUBJECTIVE VISUAL DISTURBANCE UNSPECIFIED - PSYCHOPHYSICAL VISUAL DISTURBANCES | |
368.2 | DIPLOPIA |
BINOCULAR VISION DISORDER UNSPECIFIED - ABNORMAL RETINAL CORRESPONDENCE | |
VISUAL FIELD DEFECT UNSPECIFIED - HETERONYMOUS BILATERAL FIELD DEFECTS | |
368.51 | PROTAN DEFECT |
368.55 | ACQUIRED COLOR VISION DEFICIENCIES |
368.59 | OTHER COLOR VISION DEFICIENCIES |
NIGHT BLINDNESS UNSPECIFIED - OTHER NIGHT BLINDNESS | |
OTHER SPECIFIED VISUAL DISTURBANCES - UNSPECIFIED VISUAL DISTURBANCE | |
BLINDNESS OF BOTH EYES IMPAIRMENT LEVEL NOT FURTHER SPECIFIED - BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT | |
BLINDNESS ONE EYE; LOW VISION OTHER EYE - BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT | |
LOW VISION BOTH EYES NOT OTHERWISE SPECIFIED - BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: MODERATE VISION IMPAIRMENT | |
369.3 | UNQUALIFIED VISUAL LOSS BOTH EYES |
369.4 | LEGAL BLINDNESS AS DEFINED IN U.S.A. |
BLINDNESS ONE EYE NOT OTHERWISE SPECIFIED - ONE EYE: PROFOUND VISION IMPAIRMENT; OTHER EYE: NORMAL VISION | |
LOW VISION ONE EYE NOT OTHERWISE SPECIFIED - ONE EYE: MODERATE VISION IMPAIRMENT; OTHER EYE: NORMAL VISION | |
UNQUALIFIED VISUAL LOSS ONE EYE - UNSPECIFIED VISUAL LOSS | |
OTHER INFLAMMATIONS OF EYELIDS - UNSPECIFIED INFLAMMATION OF EYELID | |
PTOSIS OF EYELID UNSPECIFIED - BLEPHAROCHALASIS | |
374.87 | DERMATOCHALASIS |
ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - ORBITAL TENONITIS | |
376.10 | CHRONIC INFLAMMATION OF ORBIT UNSPECIFIED |
376.11 | ORBITAL GRANULOMA |
376.13 | PARASITIC INFESTATION OF ORBIT |
376.21 | THYROTOXIC EXOPHTHALMOS |
376.22 | EXOPHTHALMIC OPHTHALMOPLEGIA |
EXOPHTHALMOS UNSPECIFIED - LATERAL DISPLACEMENT OF GLOBE | |
DEFORMITY OF ORBIT UNSPECIFIED - DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY | |
ENOPHTHALMOS UNSPECIFIED AS TO CAUSE - ENOPHTHALMOS DUE TO TRAUMA OR SURGERY | |
376.6 | RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT |
ORBITAL CYSTS - OTHER ORBITAL DISORDERS | |
376.9 | UNSPECIFIED DISORDER OF ORBIT |
PAPILLEDEMA UNSPECIFIED - FOSTER-KENNEDY SYNDROME | |
OPTIC ATROPHY UNSPECIFIED - HEREDITARY OPTIC ATROPHY | |
DRUSEN OF OPTIC DISC - PSEUDOPAPILLEDEMA | |
OPTIC NEURITIS UNSPECIFIED - OTHER OPTIC NEURITIS | |
ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE | |
DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS | |
DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS - DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH INFLAMMATORY DISORDERS | |
DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS - CORTICAL BLINDNESS | |
377.9 | UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS |
PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA | |
PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS | |
379.45 | ARGYLL ROBERTSON PUPIL ATYPICAL |
NYSTAGMUS UNSPECIFIED - OTHER IRREGULARITIES OF EYE MOVEMENTS | |
INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, UNSPECIFIED - INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 3 | |
379.92 | SWELLING OR MASS OF EYE |
430 | SUBARACHNOID HEMORRHAGE |
431 | INTRACEREBRAL HEMORRHAGE |
NONTRAUMATIC EXTRADURAL HEMORRHAGE - UNSPECIFIED INTRACRANIAL HEMORRHAGE | |
OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION | |
OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION | |
OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION | |
OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION | |
OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION | |
OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION | |
CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION | |
CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION | |
CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION | |
BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA | |
436 | ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE |
CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR DISEASE | |
446.5 | GIANT CELL ARTERITIS |
701.8 | OTHER SPECIFIED HYPERTROPHIC AND ATROPHIC CONDITIONS OF SKIN |
714.0 | RHEUMATOID ARTHRITIS |
742.3 | CONGENITAL HYDROCEPHALUS |
BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES | |
743.44 | SPECIFIED CONGENITAL ANOMALIES OF ANTERIOR CHAMBER CHAMBER ANGLE AND RELATED STRUCTURES |
743.45 | ANIRIDIA |
VITREOUS ANOMALIES CONGENITAL - OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT | |
743.61 | CONGENITAL PTOSIS OF EYELID |
784.0 | HEADACHE |
OPTIC NERVE INJURY - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS | |
951.0 | INJURY TO OCULOMOTOR NERVE |
961.4 | POISONING BY ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA |
980.1 | TOXIC EFFECT OF METHYL ALCOHOL |
E931.4 | ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE |
V58.65 | LONG-TERM (CURRENT) USE OF STEROIDS |
V58.66 | LONG-TERM (CURRENT) USE OF ASPIRIN |
V58.67 | LONG-TERM (CURRENT) USE OF INSULIN |
V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
V65.2 | PERSON FEIGNING ILLNESS |
V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
V71.81 | OBSERVATION FOR SUSPECTED ABUSE AND NEGLECT |
V71.89 | OBSERVATION FOR OTHER SPECIFIED SUSPECTED CONDITIONS |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should described the service performed.
- When reporting ICD-9 code(s) V58.65, V58.69 and/or V67.51, the medical record must reflect the medication administered as well as the underlying condition for which it was given.
- The medical record documentation must clearly indicate the medical necessity of the visual field testing. Also, the results of the visual field test must be maintained in the patient’s medical record.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27545
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
08/01/2008 |
L27545 |
LCD effective 08/01/2008 for DC Part A, Maryland Part A, and Pennsylvania Part A. LCD is now effective for DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
05/23/2008 |
L27545 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D54 |
Original LCD posted for comment. |
Last Reviewed On
07/31/2008
Related Documents
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