CPT - 92002 -92004, 92012, 92014 Ophthalmological Services, General and Diagnostic

Procedure code and Description

92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient

92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits

92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

92014 Ophthalmological services: medical examination and evaluation, comprehensive, established patient

Medical Examinations and Evaluations with Initiation/Continuation of Diagnostic and Treatment Program:

CPT codes 92002-92014 are for medical examination and evaluation with initiation or continuation of a diagnostic and treatment program. The intermediate services (92002, 92012) describe an evaluation of a new or existing condition complicated with a new diagnostic or management problem with initiation of a  diagnostic and treatment program. They include the provision of history, general medical observation,external ocular and adnexal examination and other diagnostic procedures as indicated, including mydriasis for ophthalmoscopy. The comprehensive services include a general examination of the complete visual system and always include initiation of diagnostic and treatment programs.

These services are valued in relationship to E/M services, though past Medicare fee schedule work relative value unit cross walks from ophthalmological services to E/M no longer exist. Nonetheless, the valuations provide some understanding of the type of medical decision-making (MDM) that might be expected. 92002 is closest to 99202 (low or moderate MDM) and 92004 is between 99203 and 99204 (moderate to high MDM). Code 92012 is closest to 99213 (low to moderate MDM) and 92014 is closest to 99214 (moderate to high MDM).

These services require that the patient needs and receives care for a condition other than refractive error. They are not for screening/preventive eye examinations, prescription of lenses or monitoring of contact lenses for refractive error correction (i.e. other than bandage lenses or keratoconus lens therapy). There must be initiation of treatment or a diagnostic plan for a comprehensive service to be reported. An intermediate service requires initiation or continuation of a diagnostic or treatment plan. Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be reported using 92002-92014.

A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014.

Medical examinations and evaluations with initiation/continuation of treatment or diagnostic programs for the treatment of disease are typically covered services without limitation. Ophthalmologic screening/preventive exams and exams for refractive error, commonly referred to as “Routine Eye Exams”, are typically limited benefit services, e.g. one every 24 months. Glaucoma screening for high risk Medicare beneficiaries is covered once every 12 months and should be reported with HCPCSII code.

Reporting screening, preventive or refractive error services with codes 92002-92014 is misrepresentation of the service, potentially to manipulate eligibility for benefits and is fraud. If the member has no coverage for a routine eye exam or lens services, it is appropriate to inform the member of their financial responsibility. Do not provide the member with a receipt for 92002-92014 if providing a non-covered preventive/screening Routine Eye Exam service as the member may seek clarification from BCBSRI and these services are typically covered.

Routine Ophthalmological Evaluation, Including Refraction: HCPCS Codes S0620 and S0621 are used for these services for the new and established patient, respectively. If during the course of an evaluation it is necessary to initiate a treatment or diagnostic program, the appropriate CPT code (92002-92014) may be reported instead. An insignificant or trivial problem/abnormality that is encountered in the process of performing the routine examination and which does not require significant additional work would not warrant use of the CPT code.

There are two levels of general ophthalmologic services: intermediate and comprehensive, as described in CPT coding documents. These codes are appropriate for services to new or established patients when the level of service includes several routine optometric/ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry and motor evaluation that are integrated with and cannot be separated from the diagnostic evaluation. Itemization of individual service components is not applicable.
Procedures that may be included as part of general ophthalmologic services and may not be reported separately nor billed are:

  • Laser interferometry.
  • Potential acuity meter.
  • Keratometry.
  • Exophthalmometry.
  • Transillumination.
  • Corneal sensation.
  • Tear film adequacy.
  • Schirmer’s test.
  • Slit lamp.
  • General medical observation.

Comprehensive level of service requires an evaluation of the complete visual system. This comprehensive service constitutes a single service entity but need not be performed at one session. The service includes history, general medical observation, external and conjunctival inspection, ophthalmoscopic examination, gross visual fields and basic sensorimotor examination. It often includes, as indicated, biomicroscopy examination with cycloplegia or mydriasis and tonometry. It always includes a fundus examination through a dilated pupil, except when medically contraindicated, and initiation of diagnostic and treatment programs.
Initiation of a diagnostic and treatment program may include:
  • The prescription of medication, lenses and other therapy.
  • Arranging for special ophthalmological, diagnostic or treatment services.
  • Consultation.
  • Laboratory procedures.
  • Radiological services as may be indicated.
Vision screening at nursing homes or to a general population is not covered.
Correction of refractive errors (92015) is not a Medicare benefit. No payment will be made for 92015. If the purpose of the visit is for correction of refractive errors, the E/M itself is also not payable.

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
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.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
92002©
Eye exam, new patient
92004©
Eye exam, new patient
92012©
Eye exam established pat
92014©
Eye exam & treatment
When a service may be considered medically necessary Routine eye exams (CPT 92002-92014) may be considered medical necessary under the medical benefit only when a disease condition of the eye is found or reasonably suspected. See attachment I for a list of eligible diagnoses.

A screening test for defective vision in conjunction with a preventive medicine evaluation and management service when done in accordance with current American Academy of Pediatrics, American Academy of Family Practice, and/or Bright Futures guidelines by a physician, physician assistant, or advanced practice nurse clinician. 

Visual examination without refraction (CPT 92002 - 92014) may be considered medically necessary when a disease state of the eye or known to affect the eye is present or reasonably suspected (see attachment I) or when an individual is undergoing long term treatment (greater than 30 days) with a high risk medication. 


When a service is considered not medically necessary Non-computer-assisted corneal topography is considered part of the evaluation/and management services of general ophthalmological services (CPT codes 92002–92014) and reimbursement for Plan contracted providers is set accordingly. Separate reimbursement is not appropriate for this procedure.
CPT 92014 - Ophthalmological services: medical examination and evaluation, with initiation or continuation ofdiagnostic and treatment program; comprehensive, established patient, 1 or more visits

.

ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 92002, 92004, 92012 and 92014:
Covered for:
017.00–017.06
Tuberculosis of skin and subcutaneous cellular tissue
017.10–017.16
Erythema nodosum with hyperactivity reaction in tuberculosis
017.20–017.26
Tuberculosis of peripherial lymph nodes
017.30–017.36
Tuberculosis of eye unspecified examination
017.40–017.46
Tuberculosis of ear
017.50–017.56
Tuberculosis of thyroid gland
017.60–017.66
Tuberculosis of adrenal glands
017.70–017.76
Tuberculosis of spleen
017.80–017.86
Tuberculosis of esophagus
017.90–017.96
Tuberculosis of other specified organs
021.3
Oculoglandular tularemia
023.8–023.9
Brucellosis
030.0–030.3
Leprosy
030.8–030.9
Leprosy
036.81
Meningococcal optic neuritis
036.9
Meningococcal infection unspecified
037
Tetanus
038.0
Streptococcal septicemia
038.10–038.12
Staphylococcal septicemia
038.19
Other staphylococcal septicemia
038.2–038.3
Septicemia
038.40–038.44
Septicemia due to gram-negative organisms
038.49
Other septicemia due to gram-negative organisms
038.8–038.9
Septicemia
039.3
Cervicofacial actinomycotic infection
039.8–039.9
Actinomycotic infections
040.0–040.3
Gas gangrene
040.81–040.82
Other specified bacterial diseases
040.89
Other specified bacterial diseases
041.00–041.05
Streptococcus
041.09
Other streptococcus
041.10–041.11
Staphylococcus
041.19
Other staphylococcus
041.2–041.7
Bacterial infection in conditions classified elsewhere and of unspecified site
041.81–041.86
Other specified bacterial infections
041.89
Other specified bacteria
041.9
Bacterial infection unspecified
042
Human immunodeficiency virus (hiv) disease
045.00–045.03
Acute paralytic poliomyelitis specified as bulbar
045.10–045.13
Acute poliomyelitis with other paralysis
045.20–045.23
Acute nonparalytic poliomyelitis
045.90–045.93
Unspecified acute poliomyelitis
046.0
Kuru
046.19
Other and unspecified Creutzfeldt-Jakob disease
046.2-046.3
Subacute sclerosing panencephalitis
046.79
Other and unspecified prion disease of central nervous system
046.8–046.9
Slow virus infection of central nervous system
047.0–047.1
Meningitis due to enterovirus
047.8–047.9
Meningitis due to enterovirus
048
Other enterovirus diseases of central nervous system
049.0–049.1
Other non-arthropod-borne viral diseases of central nervous system
049.8–049.9
Other non-arthropod-borne viral diseases of central nervous system
053.10–053.13
Herpes zoster with meningitis
053.19
Herpes zoster with other nervous system complications
053.20–053.22
Herpes zoster dermatitis of eyelid – herpes zoster iridocyclitis
053.29
Herpes zoster with other ophthalmic complications
053.8–053.9
Herpes zoster
054.2–054.3
Herpes simplex
054.40–054.44
Herpes simplex with unspecified ophthalmic complication – herpes simplex iridocyclitis
054.49
Herpes simplex with other ophthalmic complications
054.5–054.6
Herpes simplex
054.71–054.73
Herpes simplex with other specified complications
054.79
Herpes simplex with other specified complications
054.8–054.9
Herpes simplex
055.71
Measles keratoconjunctivitis
055.8
Measles with unspecified complication
076.0–076.1
Trachoma initial stage – trachoma active stage
076.9
Trachoma unspecified
077.0–077.4
Inclusion conjunctivitis – epidemic hemorrhagic conjunctivitis
077.8
Other viral conjunctivitis
077.98–077.99
Other diseases of conjunctiva due to viruses and chlamydiae
078.0
Molluscum contagiosum
078.3
Cat-scratch disease
078.5
Cytomegaloviral disease
078.89
Other specified diseases due to viruses
079.0–079.4
Viral and chlamydial infection in conditions classified elsewhere and of unspecified site
079.50–079.53
Retrovirus unspecified – human immunodeficiency virus type 2 [hiv-2]
079.59
Other specified retrovirus
079.82
Sars-associated coronavirus infection
080
Louse-borne (epidemic) typhus
081.0–081.2
Other typhus
081.9
Typhus unspecified
082.0–082.3
Tick-borne rickettsioses
082.40–082.41
Ehrlichiosis
091.50–091.52
Syphilitic uveitis unspecified – syphilitic iridocyclitis (secondary)
094.0–094.1
Tabes dorsalis – general paresis
094.3
Asymptomatic neurosyphilis
094.81–094.87
Syphilitic encephalitis – syphilitic ruptured cerebral aneurysm
095.0
Syphilitic episcleritis
098.40–098.43
Gonococcal conjunctivitis (neonatorum) – gonococcal keratitis
098.49
Other gonococcal infection of eye
099.3
Reiter’s disease
099.41
Other nongonococcal urethritis chlamydia trachomatis
115.02
Histoplasma capsulatum retinitis
115.09
Infection by histoplasma capsulatum with other manifestation
115.12
Histoplasma duboisii retinitis
115.19
Infection by histoplasma duboisii with other manifestation
115.92
Histoplasmosis retinitis unspecified
115.99
Histoplasmosis unspecified with other manifestation
125.2
Loiasis
130.0–130.5
Meningoencephalitis due to toxoplasmosis – hepatitis due to toxoplasmosis
135
Sarcoidosis
136.1
Behcet’s syndrome
171.0
Malignant neoplasm of connective and other soft tissue of head face and neck
172.1
Malignant melanoma of skin of eyelid including canthus
173.1
Other malignant neoplasm of skin of eyelid including canthus
190.0–190.9
Malignant neoplasm of eyeball except conjunctiva cornea retina and choroid
191.1–191.9
Malignant neoplasm of brain
192.0–192.1
Malignant neoplasm of other and unspecified parts of nervous system
192.3
Malignant neoplasm of spinal meninges
192.8–192.9
Malignant neoplasm of other and unspecified sites of nervous system
194.3
Malignant neoplasm of pituitary gland and craniopharyngeal duct
198.3–198.4
Secondary malignant neoplasm of other specified sites
216.1
Benign neoplasm of eyelid including canthus
224.0–224.9
Benign neoplasm of eye
225.0–225.4
Benign neoplasm of brain – benign neoplasm of spinal meninges
225.8–225.9
Benign neoplasm of brain and other parts of nervous system
228.03
Hemangioma of retina
232.1
Carcinoma in situ of eyelid including canthus
234.0
Carcinoma in situ of eye
237.0
Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
241.9
Unspecified nontoxic nodular goiter
242.00–242.01
Toxic diffuse goiter
242.10–242.11
Toxic uninodular goiter
242.20–242.21
Toxic multinodular goiter
242.30–242.31
Toxic nodular goiter unspecified
242.40–242.41
Thyrotoxicosis from ectopic thyroid nodule
242.80–242.81
Thyrotoxicosis of other specified origin
242.90–242.91
Thyrotoxicosis without mention of goiter or other cause
244.9
Unspecified acquired hypothyroidism
246.8–246.9
Other disorders of thyroid
250.00–250.03
Diabetes mellitus without mention of complication
250.10–250.13
Diabetes with ketoacidosis
250.20–250.23
Diabetes with hyperosmolarity
250.30–250.33
Diabetes with other coma
250.40–250.43
Diabetes with renal manifestations
250.50–250.53
Diabetes with ophthalmic manifestations
250.60–250.63
Diabetes with neurological manifestations
250.70–250.73
Diabetes with peripheral circulatory disorders
250.80–250.83
Diabetes with other specified manifestations
250.90–250.93
Diabetes with unspecified complication
264.0–264.9
Vitamin a deficiency with conjunctival xerosis – unspecified vitamin a deficiency
282.60–282.64
Sickle-cell disease
282.68–282.69
Sickle-cell disease
300.11
Conversion disorder
333.81
Blepharospasm
339.89
Other headache syndromes
340
Multiple sclerosis
341.0
Neuromyelitis optica
346.00–346.03
Classical migraine
346.10–346.13
Common migraine
346.20–346.23
Variants of migraine
346.30-346.33
Hemiplegic migraine, without mention of intractable migraine without mention of status migrainosus
346.40-346.43
Menstrual migraine, without mention of intractable migraine without mention of status migrainosus
346.50-346.53
Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status migrainosus
346.60-346.63
Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus
346.70-346.73
Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus
346.80–346.83
Other forms of migraine
346.90–346.92
Migraine unspecified
348.2
Benign intracranial hypertension
350.1
Trigeminal neuralgia
351.0–351.1
Facial nerve disorders
351.8–351.9
Other facial nerve disorders
352.6
Multiple cranial nerve palsies
357.2
Polyneuropathy in diabetes
360.00–360.04
Purulent endophthalmitis
360.11–360.14
Other endophthalmitis
360.19
Other endophthalmitis
360.20–360.21
Degenerative disorders of globe
360.23–360.24
Degenerative disorders of globe
360.29
Other degenerative disorders of globe
360.30–360.34
Hypotony of eye
360.40–360.44
Degenerated conditions of globe
360.50–360.55
Retained (old) intraocular foreign body, magnetic
360.59
Intraocular foreign body magnetic in other or multiple sites
360.60–360.65
Retained (old) intraocular foreign body, nonmagnetic
360.69
Intraocular foreign body in other or multiple sites
360.81
Luxation of globe
360.89
Other disorders of globe
360.9
Unspecified disorder of globe
361.00–361.07
Retinal detachment with retinal defect
361.10–361.14
Retinoschisis and retinal cysts
361.19
Other retinoschisis and retinal cysts
361.2
Serous retinal detach
361.30–361.33
Retinal defect without detachment
361.81
Traction detach of retina
361.89
Other forms of retinal detach
361.9
Unspecified retinal detach
362.01–362.07
Diabetic retinopathy
362.10–362.18
Other background retinopathy and retinal vascular changes
362.20-362.27
Retinopathy of prematurity, unspecified
362.29
Other nondiabetic proliferative retinopathy
362.30–362.37
Retinal vascular occlusion
362.40–362.43
Separation of retinal layers
362.50–362.57
Degeneration of macula and posterior pole
362.60–362.66
Peripheral retinal degenerations
362.70–362.77
Hereditary retinal dystrophies
362.81–362.85
Other retinal disorders
362.89
Other retinal disorders
362.9
Unspecified retinal disorder
363.00–363.01
Focal chorioretinitis and focal retinochoroiditis
363.03–363.08
Focal chorioretinitis and focal retinochoroiditis
363.10–363.15
Disseminated chorioretinitis and disseminated retinochoroiditis
363.20–363.22
Other and unspecified forms of chorioretinitis and retinochoroiditis
363.30–363.35
Chorioretinal scars
363.40–363.43
Choroidal degenerations
363.50–363.57
Hereditary choroidal dystrophies
363.61–363.63
Choroidal hemorrhage and rupture
363.70–363.72
Choroidal detachment
363.8–363.9
Other disorders of choroid
364.00–364.05
Acute and subacute iridocyclitis
364.10–364.11
Chronic iridocyclitis
364.21–364.24
Certain types of iridocyclitis
364.3
Unspecified iridocyclitis
364.41–364.42
Vascular disorders of iris and ciliary body
364.51–364.57
Degenerative changes of iris and ciliary body
364.59
Other iris atrophy
364.60–364.64
Cysts of iris, ciliary body and anterior chamber
364.70–364.77
Adhesions and disruptions of iris and ciliary body
364.81–364.82
Floppy iris syndrome
364.89
Other disorders of iris and ciliary body
364.9
Unspecified disorder of iris and ciliary body
365.00–365.04
Borderline glaucoma
365.10–365.15
Open-angle glaucoma
365.20–365.24
Primary angle-closure glaucoma
365.31–365.32
Corticosteroid-induced glaucoma
365.41–365.44
Glaucoma associated with congenital abnormalities, dystrophies and systemic syndromes
365.51–365.52
Glaucoma associated disorders of the lens
365.59
Glaucoma associated with other lens disorders
365.60–365.65
Glaucoma associated with ocular disorders
365.81–365.83
Other specified forms of glaucoma
365.89
Other specified glaucoma
365.9
Unspecified glaucoma
366.00–366.04
Infantile, juvenile and presenile cataract
366.09
Other and combined forms of nonsenile cataract
366.10–366.19
Senile cataract
366.20–366.23
Traumatic cataract
366.30–366.34
Cataract secondary to ocular disorders
366.41–366.46
Cataract associated with other disorders
366.50–366.53
After-cataract
366.8–366.9
Other cataract
368.00–368.03
Amblyopia ex anopsia
368.10–368.16
Subjective visual disturbances
368.2
Diplopia
368.30–368.34
Other disorders of binocular vision
368.40–368.47
Visual field defects
368.51–368.55
Color vision deficiencies
368.59
Other color vision deficiencies
368.60–368.63
Night blindness
368.69
Other night blindness
368.8–368.9
Other specified visual disturbances
369.3–369.4
Blindness and low vision
369.60
Blindness one eye not otherwise specified
369.8–369.9
Unqualified visual loss one eye
370.01–370.07
Corneal ulcer
370.20–370.24
Superficial keratitis without conjunctivitis
370.31–370.35
Certain types of keratoconjunctivitis
370.40
Keratoconjunctivitis unspecified
370.44
Keratitis or keratoconjunctivitis in exanthema
370.49
Other keratoconjunctivitis unspecified
370.50
Interstitial keratitis unspecified
370.52
Diffuse interstitial keratitis
370.54–370.55
Interstitial and deep keratitis
370.59
Other interstitial and deep keratitis
370.60–370.64
Corneal neovascularization
370.8–370.9
Other keratitis
371.00–371.05
Corneal scars and opacities
371.10–371.16
Corneal pigmentations and deposits
371.20–371.24
Corneal edema
371.30–371.32
Changes of corneal membranes
371.40–371.46
Corneal degenerations
371.48–371.49
Corneal degenerations
371.50–371.58
Hereditary corneal dystrophies
371.60–371.62
Keratoconus
371.71–371.73
Other corneal deformities
371.81–371.82
Other corneal disorders
371.89
Other corneal disorders
371.9
Unspecified corneal disorder
372.00–372.06
Acute conjunctivitis
372.10–372.15
Chronic conjunctivitis
372.20–372.22
Blepharoconjunctivitis
372.30–372.31
Other and unspecified conjunctivitis
372.33–372.34
Conjunctivitis in mucocutaneous disease
372.39
Other conjunctivitis
372.40–372.45
Pterygium
372.50–372.56
Conjunctival degenerations and deposits
372.61–372.64
Conjunctival scars
372.71–372.75
Conjunctival vascular disorders and cysts
372.81
Conjunctivochalasis
372.89
Other disorders of conjunctiva
372.9
Unspecified disorder of conjunctiva
373.00–373.02
Blepharitis
373.11–373.13
Hordeolum and other deep inflammation of the eyelid
373.2
Chalazion
373.31–373.34
Noninfectious dermatoses of eyelid
373.4–373.6
Inflammation of eyelids
373.8–373.9
Other inflammations of eyelids
374.00–374.05
Entropion and trichiasis of eyelid
374.10–374.14
Ectropion
374.20–374.23
Lagophthalmos
374.30–374.32
Ptosis of eyelid
374.34
Blepharochalasis
374.41
Lid retraction or lag
374.43–374.46
Other disorders affecting eyelid function
374.50–374.56
Degenerative disorders of eyelid and periocular area
374.81–374.87
Other disorders of eyelid
374.89
Other disorders of eyelid
374.9
Unspecified disorder of eyelid
375.00–375.03
Dacryoadenitis
375.11–375.16
Other disorders of lacrimal gland
375.20–375.22
Epiphora
375.30–375.33
Acute and unspecified inflammation of lacrimal passages
375.41–375.43
Chronic inflammation of lacrimal passages
375.51–375.54
Stenosis and insufficiency of lacrimal passages
375.56–375.57
Stenosis and insufficiency of lacrimal passages
375.61
Lacrimal fistula
375.69
Other changes of lacrimal passages
375.81
Granuloma of lacrimal passages
375.89
Other disorders of lacrimal system
375.9
Unspecified disorder of lacrimal system
376.00–376.04
Acute inflammation of orbit
376.10–376.13
Chronic inflammatory disorders orbit
376.21–376.22
Endocrine exophthalmos
376.30–376.36
Other exophthalmic conditions
376.40–376.47
Deformity of orbit
376.50–376.52
Enophthalmos
376.6
Retained (old) foreign body following penetrating wound of orbit
376.81–376.82
Orbital disorders
376.89
Other orbital disorders
376.9
Unspecified disorder of orbit
377.00–377.04
Papilledema
377.10–377.16
Optic atrophy
377.30–377.34
Optic neuritis
377.39
Other optic neuritis
377.41–377.43
Other disorders of optic nerve
377.49
Other disorders of optic nerve
377.51–377.54
Disorders of optic chiasm
377.61–377.63
Disorders of other visual pathways
377.71–377.73
Disorders of visual cortex
377.75
Cortical blindness
377.9
Unspecified disorder of optic nerve and visual pathways
378.00–378.08
Esotropia
378.10–378.18
Exotropia
378.20–378.24
Intermittent heterotropia
378.30–378.35
Other and unspecified heterotropia
378.40–378.45
Heterophoria
378.50–378.56
Paralytic strabismus
378.60–378.63
Mechanical strabismus
378.71–378.73
Other specified strabismus
378.81–378.87
Other dissociated binocular eye movements
378.9
Unspecified disorder of eye movements
379.00–379.07
Scleritis and episcleritis
379.09
Other scleritis
379.11–379.16
Other disorders of sclera
379.19
Other scleral disorders
379.21–379.26
Disorders of vitreous body
379.29
Other disorders of vitreous
379.31–379.34
Aphakia and other disorders of lens
379.39
Other disorders of lens
379.40–379.43
Anomalies of pupillary function
379.45–379.46
Anomalies of pupillary function
379.50–379.59
Nystagmus and other irregular eye movements
379.60–379.63Inflam postproc bleb
379.8
Other specified disorders of eye and adnexa
379.90–379.93
Other disorder of eye and adnexa
379.99
Other ill-defined disorders of eye
446.5
Giant cell arteritis
648.00–648.04
Diabetes mellitus of mother complicating pregnancy childbirth or the puerperium unspecified as to episode of care – postpartum diabetes mellitus
694.61
Benign mucous membrane pemphigoid with ocular involvement
695.10-695.15
Erythema multiforme, unspecified
695.19
Other erythema multiforme
695.3
Rosacea
710.0
Systemic lupus erythematosus
710.2
Sicca syndrome
743.00
Clinical anophthalmos unspecified
743.03
Cystic eyeball congenital
743.06
Cryptophthalmos
743.10–743.12
Microphthalmos
743.20–743.22
Buphthalmos
743.30–743.37
Congenital cataract and lens anomalies
743.39
Other congenital cataract and lens anomalies
743.41–743.49
Coloboma and other anomalies of anterior segment
743.51–743.59
Congenital anomalies of posterior segment
743.61–743.66
Congenital anomalies of eyelids, lacrimal system and orbit
743.69
Other congenital anomalies of eyelids lacrimal system and orbit
743.8–743.9
Other congenital anomalies of eye
781.93
Ocular torticollis
784.0
Headache
870.0–870.4
Laceration of skin of eyelid and periocular area
870.8–870.9
Other specified open wounds of ocular adnexa
871.0–871.7
Open wound of eyeball
871.9
Unspecified open wound of eyeball
909.5
Late effect of adverse effect of drug medicinal or biological substance
918.0–918.2
Superficial injury of eye and adnexa
918.9
Other and unspecified superficial injuries of eye
921.0–921.3
Contusion of eye and adnexa
921.9
Unspecified contusion of eye
925.1
Crushing injury of face and scalp
930.0–930.2
Foreign body on external eye
930.8–930.9
Foreign body on external eye
940.0–940.5
Burn confined to eye and adnexa
940.9
Unspecified burn of eye and adnexa
941.02
Burn of unspecified degree of eye (with other parts of face head and neck)
941.12
Erythema due to burn (first degree) of eye (with other parts face head and neck)
941.22
Blisters with epidermal loss due to burn (second degree) of eye (with other parts of face head and neck)
941.32
Full-thickness skin loss due to burn (third degree nos) of eye (with other parts of face head and neck)
941.42
Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face head and neck) without loss of body part
941.52
Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face head and neck) with loss of a body part
950.0–950.3
Optic nerve injury – injury to visual cortex
950.9
Injury to unspecified optic nerve and pathways
951.0–951.4
Injury to oculomotor nerve – injury to facial nerve
976.5
Poisoning by eye anti-infectives and other eye drugs
996.51
Mechanical complication of prosthetic corneal graft
996.53
Mechanical complication of prosthetic ocular lens prosthesis
996.59
Mechanical complication of other implant and internal device not elsewhere classified
996.69
Infection and inflammatory reaction due to other internal prosthetic device implant and graft
996.70
Other complications due to unspecified device implant and graft
997.99
Complications affecting other specified body systems not elsewhere classified
998.31–998.32
Disruption of operation wound
998.51
Infected postoperative seroma
998.59
Other postoperative infection
998.6
Persistent postoperative fistula not elsewhere classified
998.82
Cataract fragments in eye following cataract surgery
998.89
Other specified complications of procedures not elsewhere classified
998.9
Unspecified complication of procedure not elsewhere classified
V41.0
Problems with sight
V41.1
Other eye problems
V42.5
Cornea replaced by transplant
V43.0
Eye globe replaced by other means
V43.1
Lens replaced by other means
V45.61
Cataract extraction status
V45.69
Other states following surgery of eye and adnexa
V45.78
Acquired absence of organ eye
V52.2
Fitting and adjustment of artificial eye
V57.4
Care involving orthoptic training
V58.62
Long-term (current) use of antibiotics
V58.65
Long-term (current) use of steroids
V58.69
Long-term (current) use of other medications
V59.5
Cornea donors
V67.51
Follow-up examination following completed treatment with high-risk medication not elsewhere classified
V71.1
Observation for suspected malignant neoplasm
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

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