Visual Fields (L31348)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L31348 LCD Title Visual Fields Contractor's Determination Number OPHTH-054 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 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. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 04/15/2011 Original Determination Ending Date Revision Effective Date For services performed on or after 10/01/2011 Revision Ending Date |
CMS National Coverage Policy
Title
XVIII of the Social Security Act, Section 1862(a)(1)(A). This section
allows coverage and payment for only those services that are considered
to be medically reasonable and necessary.
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Medicare Benefit Policy Manual, 100-2, 16, Section 90
Code of Federal Regulations:
42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Medicare Benefit Policy Manual, 100-2, 16, Section 90
Code of Federal Regulations:
42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).
Indications and Limitations of Coverage and/or Medical Necessity
Visual
fields are examined by the use of static or kinetic perimetry. The
procedure is performed separately for each eye, and measures the
combined function of the retina, the optic nerve, and the intracranial
visual pathway. It is used clinically to detect or monitor field loss
due to disease at any of these locations. Visual fields may be
determined by several methods including a tangent screen, Goldmann
perimeter, and computerized automated perimeters.
Visual field examinations will be considered medically necessary under the following conditions:
1. Disorder of the eyelids potentially affecting the visual field;
2. A documented diagnosis of glaucoma.
Stabilization or progression of glaucoma can be monitored by a visual field examination, or by such services as scanning computerized ophthalmic diagnostic imaging. This evaluation must be performed at regular intervals to determine that the prescribed management is adequately controlling progression of disease to the degree possible. The frequency of such examinations is dependent on clinical judgment as well as 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.
3. A diagnosis of glaucoma is suspected with supporting evidence documented.
A suspected diagnosis of glaucoma is evidenced by an increase in intraocular pressure over time, intraocular pressures of 22 mm Hg or more, 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, a change in the cup-to-disc ratio over time, disc hemorrhage, or an absent, thinned or notched neural rim. Additional possible indicators of glaucoma suspicion are fallout of the retinal nerve fiber layer, optic atrophy (pallor of the optic nerve), corneal endothelial pigment deposits (Krukenburg's Spindle), dense pigmentation of the trabecular meshwork as evidenced by gonioscopy, pseudoexfoliation of the lens or dense exfoliative deposits on the trabecular meshwork as evidenced by gonioscopy.
4. A documented disorder of the optic nerve, the neurologic visual pathway, or retina.
Patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients who are about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field would not be indicated.
5. A recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.
6. A recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia or giant cell arteritis.
7. A history of a cerebral aneurysm, pituitary tumor, occipital tumor or other condition potentially affecting the visual fields.
8. A visual field defect demonstrated by gross visual field testing (e.g., confrontation testing).
9. An initial workup for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.
10. A disorder of the orbit, potentially affecting the visual field (e.g. orbital tumor, thyroid disease, etc.).
11. A significant eye injury.
12. Unexplained visual loss which may be described as "trouble seeing or vision going in and out."
13. A pale or swollen optic nerve documented by a recent examination.
14. New functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things).
15. Medication treatment (e.g., hydroxychloroquine) which has a high risk of potentially affecting the visual system.
16. Initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70.
Limitations
Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological services and should not be reported separately.
Frequency of examinations for a diagnosis of macular degeneration or an experienced central vision loss (or to evaluate the results of a surgical intervention or for the possible need for surgical intervention) is dictated by stage of disease or degree of risk factors, just as with glaucoma evaluation.
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
Visual field examinations will be considered medically necessary under the following conditions:
1. Disorder of the eyelids potentially affecting the visual field;
2. A documented diagnosis of glaucoma.
Stabilization or progression of glaucoma can be monitored by a visual field examination, or by such services as scanning computerized ophthalmic diagnostic imaging. This evaluation must be performed at regular intervals to determine that the prescribed management is adequately controlling progression of disease to the degree possible. The frequency of such examinations is dependent on clinical judgment as well as 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.
3. A diagnosis of glaucoma is suspected with supporting evidence documented.
A suspected diagnosis of glaucoma is evidenced by an increase in intraocular pressure over time, intraocular pressures of 22 mm Hg or more, 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, a change in the cup-to-disc ratio over time, disc hemorrhage, or an absent, thinned or notched neural rim. Additional possible indicators of glaucoma suspicion are fallout of the retinal nerve fiber layer, optic atrophy (pallor of the optic nerve), corneal endothelial pigment deposits (Krukenburg's Spindle), dense pigmentation of the trabecular meshwork as evidenced by gonioscopy, pseudoexfoliation of the lens or dense exfoliative deposits on the trabecular meshwork as evidenced by gonioscopy.
4. A documented disorder of the optic nerve, the neurologic visual pathway, or retina.
Patients with a previously diagnosed retinal detachment do not need a pretreatment visual field examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field unless other presenting symptomatology is documented. In patients who are about to undergo cataract extraction, who do not have glaucoma and are not glaucoma suspects, a visual field would not be indicated.
5. A recent intracranial hemorrhage, an intracranial mass or a recent measurement of increased intracranial pressure with or without visual symptomatology.
6. A recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia or giant cell arteritis.
7. A history of a cerebral aneurysm, pituitary tumor, occipital tumor or other condition potentially affecting the visual fields.
8. A visual field defect demonstrated by gross visual field testing (e.g., confrontation testing).
9. An initial workup for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis.
10. A disorder of the orbit, potentially affecting the visual field (e.g. orbital tumor, thyroid disease, etc.).
11. A significant eye injury.
12. Unexplained visual loss which may be described as "trouble seeing or vision going in and out."
13. A pale or swollen optic nerve documented by a recent examination.
14. New functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things).
15. Medication treatment (e.g., hydroxychloroquine) which has a high risk of potentially affecting the visual system.
16. Initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70.
Limitations
Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological services and should not be reported separately.
Frequency of examinations for a diagnosis of macular degeneration or an experienced central vision loss (or to evaluate the results of a surgical intervention or for the possible need for surgical intervention) is dictated by stage of disease or degree of risk factors, just as with glaucoma evaluation.
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
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.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 071x | Clinic - Rural Health |
| 073x | Clinic - Freestanding |
| 074x | Clinic - Outpatient Rehabilitation Facility (ORF) |
| 075x | Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) |
| 077x | Clinic - Federally Qualified Health Center (FQHC) |
| 085x | Critical Access Hospital |
Revenue Codes:
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 FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
CPT/HCPCS 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 FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
| 0510 | Clinic - General Classification |
| 0519 | Clinic - Other Clinic |
| 0761 | Specialty Services - Treatment Room |
| 0920 | Other Diagnostic Services - General Classification |
| 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
| 094.3 | ASYMPTOMATIC NEUROSYPHILIS |
| 094.84 | SYPHILITIC OPTIC ATROPHY |
| 094.85 | SYPHILITIC RETROBULBAR NEURITIS |
| 095.0 | SYPHILITIC EPISCLERITIS |
| 130.2 | CHORIORETINITIS DUE TO TOXOPLASMOSIS |
| 190.0 - 190.9 | MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED |
| 191.0 - 191.9 | MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE |
| 192.0 - 192.9 | MALIGNANT NEOPLASM OF CRANIAL NERVES - MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED |
| 194.3 | MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
| 198.3 | SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD |
| 198.4 | SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM |
| 224.0 - 224.9 | 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 |
| 227.3 | BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
| 228.02 | HEMANGIOMA OF INTRACRANIAL STRUCTURES |
| 228.03 | HEMANGIOMA OF RETINA |
| 234.0 | CARCINOMA IN SITU OF EYE |
| 237.0 | NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT |
| 237.70 - 237.79 | NEUROFIBROMATOSIS UNSPECIFIED - OTHER NEUROFIBROMATOSIS |
| 237.9 | NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM |
| 238.8 | NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES |
| 239.6 | NEOPLASM OF UNSPECIFIED NATURE OF BRAIN |
| 239.81 | NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID |
| 242.00 - 242.91 | TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM |
| 250.50 - 250.53 | DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 259.8 | OTHER SPECIFIED ENDOCRINE DISORDERS |
| 264.0 - 264.9 | VITAMIN A DEFICIENCY WITH CONJUNCTIVAL XEROSIS - UNSPECIFIED VITAMIN A DEFICIENCY |
| 282.60 - 282.69 | SICKLE-CELL DISEASE UNSPECIFIED - OTHER SICKLE-CELL DISEASE WITH CRISIS |
| 300.11 | CONVERSION DISORDER |
| 340 | MULTIPLE SCLEROSIS |
| 341.9 | DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED |
| 346.00 - 346.93 | MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS |
| 348.2 | BENIGN INTRACRANIAL HYPERTENSION |
| 349.82 | TOXIC ENCEPHALOPATHY |
| 360.23 | SIDEROSIS OF GLOBE |
| 360.29 | OTHER DEGENERATIVE DISORDERS OF GLOBE |
| 361.00 - 361.07 | RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL |
| 361.10 - 361.19 | RETINOSCHISIS UNSPECIFIED - OTHER RETINOSCHISIS AND RETINAL CYSTS |
| 361.2 | SEROUS RETINAL DETACH |
| 361.30 - 361.33 | RETINAL DEFECT UNSPECIFIED - 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 - 362.07 | BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA |
| 362.10 - 362.18 | BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS |
| 362.20 - 362.29 | RETINOPATHY OF PREMATURITY, UNSPECIFIED - OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY |
| 362.30 - 362.37 | RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA |
| 362.40 - 362.43 | RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM |
| 362.50 - 362.57 | MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - DRUSEN (DEGENERATIVE) OF RETINA |
| 362.60 - 362.66 | PERIPHERAL RETINAL DEGENERATION UNSPECIFIED - SECONDARY VITREORETINAL DEGENERATIONS |
| 362.70 - 362.77 | HEREDITARY RETINAL DYSTROPHY UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE |
| 362.81 - 362.89 | RETINAL HEMORRHAGE - OTHER RETINAL DISORDERS |
| 362.9 | UNSPECIFIED RETINAL DISORDER |
| 363.00 - 363.08 | FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL |
| 363.10 - 363.15 | DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY |
| 363.20 | CHORIORETINITIS UNSPECIFIED |
| 363.21 | PARS PLANITIS |
| 363.22 | HARADA'S DISEASE |
| 363.30 - 363.35 | CHORIORETINAL SCAR UNSPECIFIED - DISSEMINATED SCARS OF RETINA |
| 363.40 - 363.43 | CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID |
| 363.50 - 363.57 | HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED - 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 |
| 364.00 - 364.05 | ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - HYPOPYON |
| 364.10 - 364.11 | CHRONIC IRIDOCYCLITIS UNSPECIFIED - CHRONIC IRIDOCYCLITIS IN DISEASES CLASSIFIED ELSEWHERE |
| 364.21 - 364.24 | FUCHS' HETEROCHROMIC CYCLITIS - VOGT-KOYANAGI SYNDROME |
| 364.3 | UNSPECIFIED IRIDOCYCLITIS |
| 364.41 | HYPHEMA OF IRIS AND CILIARY BODY |
| 364.42 | RUBEOSIS IRIDIS |
| 364.51 - 364.59 | ESSENTIAL OR PROGRESSIVE IRIS ATROPHY - OTHER IRIS ATROPHY |
| 364.60 - 364.64 | IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY - EXUDATIVE CYST OF PARS PLANA |
| 364.70 - 364.77 | ADHESIONS OF IRIS UNSPECIFIED - RECESSION OF CHAMBER ANGLE OF EYE |
| 364.81 - 364.9 | FLOPPY IRIS SYNDROME - UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY |
| 365.00 - 365.9 | PREGLAUCOMA UNSPECIFIED - UNSPECIFIED GLAUCOMA |
| 366.11 | PSEUDOEXFOLIATION OF LENS CAPSULE |
| 368.00 - 368.9 | AMBLYOPIA UNSPECIFIED - UNSPECIFIED VISUAL DISTURBANCE |
| 369.00 - 369.9 | BLINDNESS OF BOTH EYES IMPAIRMENT LEVEL NOT FURTHER SPECIFIED - UNSPECIFIED VISUAL LOSS |
| 371.00 - 371.9 | CORNEAL OPACITY UNSPECIFIED - UNSPECIFIED CORNEAL DISORDER |
| 374.30 - 374.34 | PTOSIS OF EYELID UNSPECIFIED - BLEPHAROCHALASIS |
| 374.87 | DERMATOCHALASIS |
| 376.00 - 376.9 | ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - UNSPECIFIED DISORDER OF ORBIT |
| 377.00 - 377.9 | PAPILLEDEMA UNSPECIFIED - UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS |
| 379.00 - 379.99 | SCLERITIS UNSPECIFIED - OTHER ILL-DEFINED DISORDERS OF EYE |
| 430 | SUBARACHNOID HEMORRHAGE |
| 431 | INTRACEREBRAL HEMORRHAGE |
| 432.0 | NONTRAUMATIC EXTRADURAL HEMORRHAGE |
| 432.1 | SUBDURAL HEMORRHAGE |
| 433.00 - 433.91 | OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION |
| 434.00 - 434.91 | CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION |
| 435.0 - 435.9 | BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA |
| 436 | ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE |
| 437.2 | HYPERTENSIVE ENCEPHALOPATHY |
| 437.3 | CEREBRAL ANEURYSM NONRUPTURED |
| 446.5 | GIANT CELL ARTERITIS |
| 742.8 | OTHER SPECIFIED CONGENITAL ANOMALIES OF NERVOUS SYSTEM |
| 743.20 - 743.69 | BUPHTHALMOS UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF EYELIDS LACRIMAL SYSTEM AND ORBIT |
| 850.0 - 850.9 | CONCUSSION WITH NO LOSS OF CONSCIOUSNESS - CONCUSSION UNSPECIFIED |
| 851.00 - 851.99 | CORTEX (CEREBRAL) CONTUSION WITHOUT OPEN INTRACRANIAL WOUND STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED CEREBRAL LACERATION AND CONTUSION WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 852.00 - 852.59 | SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 853.00 - 853.19 | OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 854.00 - 854.19 | INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED |
| 950.0 - 950.9 | OPTIC NERVE INJURY - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS |
| 995.29 | UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE |
| V58.65 | LONG-TERM (CURRENT) USE OF STEROIDS |
| V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
| V58.71 | AFTERCARE FOLLOWING SURGERY OF THE SENSE ORGANS NOT ELSEWHERE CLASSIFIED |
| V58.72 | AFTERCARE FOLLOWING SURGERY OF THE NERVOUS SYSTEM NOT ELSEWHERE CLASSIFIED |
| V58.83 | ENCOUNTER FOR THERAPEUTIC DRUG MONITORING |
| V65.2 | PERSON FEIGNING ILLNESS |
| V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
Diagnoses that Support Medical Necessity
All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity.
ICD-9 Codes that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity
| XX000 | Not Applicable |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
All diagnoses not listed in this policy under ICD-9-CM Codes that Support Medical Necessity
General Information
The medical record
documentation must clearly indicate the medical necessity of the visual
field testing and the results of the visual field test must be
maintained in the patient's medical record.
Visual field testing is covered for diagnosis and treatment of abnormal signs, symptoms, disease or injury.
The medical record must be made available to Medicare upon request.
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
When requesting a written redetermination, (formerly appeal), providers must include all relevant documentation with the request.
There must always be a reason for performing the test since routine exams are considered screening and thus are not covered as medically reasonable and necessary.
When reporting ICD-9-CM code(s) 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.
Appendices
Visual field testing is covered for diagnosis and treatment of abnormal signs, symptoms, disease or injury.
The medical record must be made available to Medicare upon request.
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
When requesting a written redetermination, (formerly appeal), providers must include all relevant documentation with the request.
There must always be a reason for performing the test since routine exams are considered screening and thus are not covered as medically reasonable and necessary.
When reporting ICD-9-CM code(s) 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 frequency of
examinations for a diagnosis of macular degeneration or an experienced
central vision loss (or to evaluate the results of a surgical
intervention or for the possible need for surgical intervention) is
dictated by stage of disease or degree of risk factors, just as with
glaucoma evaluation.
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
Those examinations found to have been performed at a frequency greater than is necessary for reasonable medical management of the patient's condition are not covered.
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
Screening services are not a Medicare benefit.
The use of any particular device for purposes of providing a medically reasonable and necessary service under this LCD is within the discretion of the individual provider, assuming FDA approval and any other applicable regulatory criteria are met. Thus, reference to specific devices is not a subject of this LCD.
Sources of Information and Basis for Decision
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
Those examinations found to have been performed at a frequency greater than is necessary for reasonable medical management of the patient's condition are not covered.
Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.
Screening services are not a Medicare benefit.
The use of any particular device for purposes of providing a medically reasonable and necessary service under this LCD is within the discretion of the individual provider, assuming FDA approval and any other applicable regulatory criteria are met. Thus, reference to specific devices is not a subject of this LCD.
Other Medicare Contractors
Notes
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Advisory Committee Meeting Notes
Notes
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Meeting Date:
Wisconsin 09/24/2010
Illinois 09/22/2010
Michigan 09/15/2010
Minnesota 09/16/2010
Iowa, Kansas, Missouri, Nebraska 10/07/2010
Open Meeting: 09-02-2010
Start Date of Comment Period
Wisconsin 09/24/2010
Illinois 09/22/2010
Michigan 09/15/2010
Minnesota 09/16/2010
Iowa, Kansas, Missouri, Nebraska 10/07/2010
Open Meeting: 09-02-2010
10/07/2010
End Date of Comment Period
11/21/2010
Start Date of Notice Period
03/01/2011
Revision History Number
X
Revision History Explanation
10/01/2011: ICD-9-CM
2012 revisions; Added to ICD-9-CM range 365.00-365.9, new codes 365.05,
365.06, 365.70, 365.71, 365.72, 365.73 and 365.74. Added to ICD-9-CM
coding range 379.00-379.99, new code 379.27, effective 10/01/2011 (one).
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
Reason for Change
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
This LCD has no Related Documents.
LCD Attachments
Billing and Coding Guidelines 03/01/2011 (PDF - 23 KB )
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Page Last Updated: Thursday, 20-Oct-2011 15:45:42 CDT
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