Download Local Coverage Determination for Visual Field Examination (L33766)

Local Coverage Determination (LCD):
Visual Field Examination (L33766)
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Contractor Information
Contractor Name
Contract Type Contract Number Jurisdiction State(s)
First Coast Service Options, Inc. A and B MAC
09101 - MAC A
J-N
Florida
First Coast Service Options, Inc. A and B MAC
09102 - MAC B
J-N
Florida
Puerto Rico
First Coast Service Options, Inc. A and B MAC
09201 - MAC A
J-N
Virgin Islands
First Coast Service Options, Inc. A and B MAC
09202 - MAC B
J-N
Puerto Rico
First Coast Service Options, Inc. A and B MAC
09302 - MAC B
J-N
Virgin Islands
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LCD Information
Document Information
LCD ID
L33766
Original Effective Date
For services performed on or after 10/01/2015
Original ICD-9 LCD ID
L29006
Revision Effective Date
For services performed on or after 10/01/2015
LCD Title
Visual Field Examination
Revision Ending Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement
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Association. All Rights Reserved. CPT is a registered
trademark of the American Medical Association.
Applicable FARS/DFARS Apply to Government Use. Fee
schedules, relative value units, conversion factors
and/or related components are not assigned by the
AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data
contained or not contained herein.
Retirement Date
N/A
The Code on Dental Procedures and Nomenclature
(Code) is published in Current Dental Terminology
(CDT). Copyright © American Dental Association. All
rights reserved. CDT and CDT-2016 are trademarks of
the American Dental Association.
Printed on 4/26/2016. Page 1 of 9
Notice Period Start Date
N/A
Notice Period End Date
N/A
UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS
MANUAL, 2014, is copyrighted by American Hospital
Association (“AHA”), Chicago, Illinois. No portion of
OFFICIAL UB-04 MANUAL may be reproduced, sorted in
a retrieval system, or transmitted, in any form or by
any means, electronic, mechanical, photocopying,
recording or otherwise, without prior express, written
consent of AHA.” Health Forum reserves the right to
change the copyright notice from time to time upon
written notice to Company.
CMS National Coverage Policy Language quoted from CMS National Coverage Determinations (NCDs) and
coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD).
NCDs and coverage provisions in interpretive manuals are not subject to the 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:
N/A
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
The visual field is the area within which objects may be seen when the eye is fixed. To standardize testing,
several automated and computerized perimeters are available. However, manual perimeters are also utilized.
Visual field examinations will be considered medically reasonable and necessary under any of the following
conditions:
· The patient has inflammation or disorders of the eyelids potentially affecting the visual field.
· The patient has a documented diagnosis of glaucoma.
Please note: stabilization or progression of glaucoma can be monitored only by a visual field examination, and the
frequency of such examinations is dependent on the variability of intraocular pressure measurements (e.g.,
progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages,
and progressive cupping of the optic nerve.
· The patient is a glaucoma suspect as evidenced by an increase in intraocular pressure, asymmetric intraocular
measurements of greater than 2-3 mm Hg between the two eyes, or has optic nerves suspicious for glaucoma
which may be manifested as asymmetrical cupping, disc hemorrhage, or an absent or thinned temporal rim.
· The patient has a documented disorder of the optic nerve, the neurologic visual pathway, or retina.
Please note: patients with a previously diagnosed retinal detachment do not need a pretreatment visual field
examination. Additionally, patients with an established diagnosed cataract do not need a follow-up visual field
unless other presenting symptomatology is documented. In patients about to undergo cataract extraction, who do
not have glaucoma and are not glaucoma suspects, a visual field is not indicated.
· The patient has had a recent intracranial hemorrhage, an intracranial mass or a recent measurement of
increased intracranial pressure with or without visual symptomatology.
· The patient has a recently documented occlusion and/or stenosis of cerebral and precerebral arteries, a recently
diagnosed transient cerebral ischemia, or giant cell arteritis.
· The patient is having an initial workup for buphthalmos, congenital anomalies of the posterior segment, or
congenital ptosis.
· The patient has inflammation or disorders of the orbit, potentially affecting the visual field.
· The patient has sustained a significant eye injury.
· The patient has an unexplained visual loss which may be described as “trouble seeing” or “vision going in and
out”.
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· The patient has a pale or swollen optic nerve documented by a visual exam of recent origin.
· The patient is having some new functional limitations which may be due to visual field loss (e.g., reports by
family that patient is running into things).
· The patient is being evaluated initially for macular degeneration or has experienced central vision loss resulting
in vision measured at or below 20/70.
Please note: repeated examinations for a diagnosis of macular degeneration or an experienced central vision loss
are not necessary unless changes in vision are documented or to evaluate the results of a surgical intervention.
· The patient is receiving or has completed treatment of a high-risk medication that may cause visual side effects
(e.g., a patient on plaquenil may develop retinopathy).
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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
014x Hospital - Laboratory Services Provided to Non-patients
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
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.
051X Clinic - General Classification
0920 Other Diagnostic Services - General Classification
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT;
92081 LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS
LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT)
VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT;
INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR
92082
SEMIQUANTITATIVE, AUTOMATED SUPRATHRESHOLD SCREENING PROGRAM, HUMPHREY
SUPRATHRESHOLD AUTOMATIC DIAGNOSTIC TEST, OCTOPUS PROGRAM 33)
VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT;
EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND
92083 STATIC DETERMINATION WITHIN THE CENTRAL 30 DEG;, 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)
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ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: N/A
Group 1 Codes:
ICD-10 Codes
Description
A18.52 Tuberculous keratitis - Other tuberculosis of eye
A18.59
A52.12
Other cerebrospinal syphilis
A52.14 Late syphilitic encephalitis - Late syphilitic neuropathy
A52.15
A52.19
Other symptomatic neurosyphilis
A52.73
Symptomatic late syphilis of other respiratory organs
A52.76
Other genitourinary symptomatic late syphilis
A52.79
Other symptomatic late syphilis
B60.13
Keratoconjunctivitis due to Acanthamoeba
C69.00 Malignant neoplasm of unspecified conjunctiva - Malignant neoplasm of unspecified site of left
C69.92
eye
C70.0
Malignant neoplasm of cerebral meninges
C70.9
Malignant neoplasm of meninges, unspecified
Malignant neoplasm of cerebrum, except lobes and ventricles - Malignant neoplasm of brain,
C71.0 - C71.9
unspecified
C72.20 Malignant neoplasm of unspecified olfactory nerve - Malignant neoplasm of other cranial nerves
C72.59
C79.32 Secondary malignant neoplasm of cerebral meninges - Secondary malignant neoplasm of other
C79.49
parts of nervous system
D09.20 Carcinoma in situ of unspecified eye - Carcinoma in situ of left eye
D09.22
D31.00 Benign neoplasm of unspecified conjunctiva - Benign neoplasm of unspecified part of left eye
D31.92
D33.3
Benign neoplasm of cranial nerves
D35.2 - D35.3 Benign neoplasm of pituitary gland - Benign neoplasm of craniopharyngeal duct
Neoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal
D44.3 - D44.5
gland
Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system D49.7 - D49.89
Neoplasm of unspecified behavior of other specified sites
D57.00 Hb-SS disease with crisis, unspecified - Sickle-cell/Hb-C disease with crisis, unspecified
D57.219
D57.80 Other sickle-cell disorders without crisis - Other sickle-cell disorders with crisis, unspecified
D57.819
Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm - Thyrotoxicosis with toxic
E05.00 - E05.11
single thyroid nodule with thyrotoxic crisis or storm
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular
E08.36
edema - Diabetes mellitus due to underlying condition with diabetic cataract
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular
E09.36
edema - Drug or chemical induced diabetes mellitus with diabetic cataract
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 1
E10.39
diabetes mellitus with other diabetic ophthalmic complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 2
E11.39
diabetes mellitus with other diabetic ophthalmic complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.39
Other specified diabetes mellitus with other diabetic ophthalmic complication
E34.1
Other hypersecretion of intestinal hormones
E34.8
Other specified endocrine disorders
E35
Disorders of endocrine glands in diseases classified elsewhere
E50.0 - E50.9
Vitamin A deficiency with conjunctival xerosis - Vitamin A deficiency, unspecified
E64.1
Sequelae of vitamin A deficiency
Conversion disorder with motor symptom or deficit - Conversion disorder with mixed symptom
F44.4 - F44.7
presentation
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ICD-10 Codes
Description
G43.001 Migraine without aura, not intractable, with status migrainosus - Migraine, unspecified,
G43.919
intractable, without status migrainosus
Vertebro-basilar artery syndrome - Other vascular syndromes of brain in cerebrovascular
G45.0 - G46.8
diseases
G93.2
Benign intracranial hypertension
H00.011 Hordeolum externum right upper eyelid - Unspecified disorder of eyelid
H02.9
H05.00 - H05.9 Unspecified acute inflammation of orbit - Unspecified disorder of orbit
H16.001 Unspecified corneal ulcer, right eye - Unspecified keratitis
H16.9
H17.00 - H17.9 Adherent leukoma, unspecified eye - Unspecified corneal scar and opacity
Unspecified corneal deposit, right eye - Disorders of iris and ciliary body in diseases classified
H18.001 - H22
elsewhere
H25.011 Cortical age-related cataract, right eye - Unspecified cataract
H26.9
H28
Cataract in diseases classified elsewhere
H30.001 Unspecified focal chorioretinal inflammation, right eye - Other intraretinal microvascular
H35.09
abnormalities
H35.171 Retrolental fibroplasia, right eye - Secondary vitreoretinal degeneration, unspecified eye
H35.469
H35.51 Vitreoretinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium
H35.54
H35.60 - H35.9 Retinal hemorrhage, unspecified eye - Unspecified retinal disorder
H40.001 Preglaucoma, unspecified, right eye - Preglaucoma, unspecified, unspecified eye
H40.009
H40.011
Open angle with borderline findings, low risk, right eye
H40.012
Open angle with borderline findings, low risk, left eye
H40.013
Open angle with borderline findings, low risk, bilateral
H40.021
Open angle with borderline findings, high risk, right eye
H40.022
Open angle with borderline findings, high risk, left eye
H40.023
Open angle with borderline findings, high risk, bilateral
H40.031
Anatomical narrow angle, right eye
H40.032
Anatomical narrow angle, left eye
H40.033
Anatomical narrow angle, bilateral
H40.041
Steroid responder, right eye
H40.042
Steroid responder, left eye
H40.043
Steroid responder, bilateral
H40.051
Ocular hypertension, right eye
H40.052
Ocular hypertension, left eye
H40.053
Ocular hypertension, bilateral
H40.061
Primary angle closure without glaucoma damage, right eye
H40.062
Primary angle closure without glaucoma damage, left eye
H40.063
Primary angle closure without glaucoma damage, bilateral
H40.10X0 Unspecified open-angle glaucoma, stage unspecified - Glaucoma secondary to drugs, bilateral,
H40.63X4
indeterminate stage
H40.811 Glaucoma with increased episcleral venous pressure, right eye - Unspecified glaucoma
H40.9
H42
Glaucoma in diseases classified elsewhere
H44.001 Unspecified purulent endophthalmitis, right eye - Unspecified disorder of globe
H44.9
H46.00 - H47.9 Optic papillitis, unspecified eye - Unspecified disorder of visual pathways
H49.00 - H51.9 Third [oculomotor] nerve palsy, unspecified eye - Unspecified disorder of binocular movement
H53.001 Unspecified amblyopia, right eye - Legal blindness, as defined in USA
H54.8
H55.00 Unspecified nystagmus - Other irregular eye movements
H55.89
H57.8
Other specified disorders of eye and adnexa
Nontraumatic intracerebral hemorrhage in hemisphere, subcortical - Occlusion and stenosis of
I61.0 - I66.9
unspecified cerebral artery
I67.1 - I67.2
Cerebral aneurysm, nonruptured - Cerebral atherosclerosis
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ICD-10 Codes
Description
I67.4 - I67.82 Hypertensive encephalopathy - Cerebral ischemia
Reversible cerebrovascular vasoconstriction syndrome - Other cerebrovascular disorders in
I67.841 - I68.8
diseases classified elsewhere
M31.5 - M31.6 Giant cell arteritis with polymyalgia rheumatica - Other giant cell arteritis
Q10.0 - Q10.7 Congenital ptosis - Congenital malformation of orbit
Congenital malformation of vitreous humor - Congenital malformation of posterior segment of
Q14.0 - Q14.9
eye, unspecified
Q15.0
Congenital glaucoma
Q85.00
Neurofibromatosis, unspecified
Q85.03
Schwannomatosis
Q85.09
Other neurofibromatosis
R44.1
Visual hallucinations
R48.3
Visual agnosia
S00.10XA Contusion of unspecified eyelid and periocular area, initial encounter - Contusion of left eyelid
S00.12XS
and periocular area, sequela
S04.019A Injury of optic nerve, unspecified eye, initial encounter - Injury of optic nerve, unspecified eye,
S04.019S
sequela
S04.02XA Injury of optic chiasm, initial encounter - Injury of optic chiasm, sequela
S04.02XS
S04.031A Injury of optic tract and pathways, right eye, initial encounter - Injury of optic tract and
S04.039S
pathways, unspecified eye, sequela
S04.041A Injury of visual cortex, right eye, initial encounter - Injury of visual cortex, unspecified eye,
S04.049S
sequela
S04.10XA Injury of oculomotor nerve, unspecified side, initial encounter - Injury of oculomotor nerve, left
S04.12XS
side, sequela
S04.20XA Injury of trochlear nerve, unspecified side, initial encounter - Injury of trochlear nerve,
S04.20XS
unspecified side, sequela
S05.10XA Contusion of eyeball and orbital tissues, unspecified eye, initial encounter - Contusion of eyeball
S05.12XS
and orbital tissues, left eye, sequela
S05.90XA Unspecified injury of unspecified eye and orbit, initial encounter - Unspecified injury of
S05.90XS
unspecified eye and orbit, sequela
T15.00XA Foreign body in cornea, unspecified eye, initial encounter - Foreign body on external eye, part
T15.92XS
unspecified, left eye, sequela
Encounter for follow-up examination after completed treatment for conditions other than
Z09
malignant neoplasm
Z79.3
Long term (current) use of hormonal contraceptives
Z79.891
Long term (current) use of opiate analgesic
Z79.899
Other long term (current) drug therapy
ICD-10 Codes that DO NOT Support Medical Necessity N/A
ICD-10 Additional Information
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General Information
Associated Information
Documentation Requirements
Medical record documentation maintained by the performing physician must clearly indicate the medical necessity
of the service being billed. In addition, documentation that the service was performed must be included in the
patient’s medical record and available upon request. This information is normally found in the office/progress
notes, hospital notes, and/or procedure report.
Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of
Coverage and/or Medical Necessity” section of this policy.
Printed on 4/26/2016. Page 6 of 9
If the provider of the service is other than the ordering/referring physician, the provider of the service must
maintain hard copy documentation of test results and maintain hard copy documentation of test results and
interpretation along with copies of the ordering/referring physician’s order for the studies. The physician must
state the clinical indication/medical necessity for the study in this order for the test.
Utilization Guidelines
It is expected that these services would be performed as indicated by current medical literature and/or standards
of practice. When services are performed in excess of established parameters, they may be subject to review for
medical necessity.
Sources of Information and Basis for Decision
FCSO reference LCD number(s) – L29038, L29308, L29487
American Optometric Association. (2002). Care of the patient with diabetes mellitus (3rd ed.). St. Louis, MO.
Retrieved October 24, 2005 from www.guideline.gov database (003386).
American Optometric Association. (2002). Care of the patient with open angle glaucoma (2nd ed.). St. Louis, MO.
Retrieved October 24, 2005 from www.guideline.gov database (003385).
American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. (2003). Posterior
vitreous detachment, retinal breaks, and lattice degeneration. San Francisco, CA. Retrieved October 24, 2005
from www.guideline.gov database (003277).
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Revision History Information
Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History
Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a
separate and distinct row.
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Revision Revision
History
History
Date
Number
Revision History Explanation
Revision Number: 3
Publication: January 2016 Connection
LCR A/B2015-037
Reason(s) for
Change
•
Revisions Due
To ICD-10-CM
Code Changes
•
Revisions Due
To ICD-10-CM
Code Changes
•
Revisions Due
To ICD-10-CM
Code Changes
10/01/2015 R4
Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis code range H35.51-H35.54 to
the “ICD-10 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision
is for claims processed on or after 12/28/15, for dates of service on or after 10/01/15.
Revision Number: 2
Publication: November 2015 Connection
LCR A/B2015-026
10/01/2015 R3
10/01/2015 R2
10/01/2015 R1
Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes E10.39, E11.39,
E13.39, Z09, Z79.3, Z79.891, and Z79.899 to the “ICD-10 Codes that Support Medical Necessity”
section of the LCD. The effective date of this revision is for claims processed on or after 11/12/15, for
dates of service on or after 10/01/15.
Revision Number: 1
Publication: October 2015 Connection
LCR A/B2015-016
Explanation of revision: This LCD was revised to add ICD-10-CM diagnosis codes H40.001-H40.009
H40.011,H40.012,H40.013,H40.021,H40.022,H40.023,H40.031,H40.032,H40.033,H40.041,H40.042
H40.043,H40.051,H40.052,H40.053,H40.061,H40.062, and H40.063 to the “ICD-10 Codes that Support
Medical Necessity” section of the LCD. The effective date of this revision is based on date of service.
• Provider
The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM
LCD’s language and coding.
Education/Guidance
Printed on 4/26/2016. Page 8 of 9
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Associated Documents
Attachments N/A
Related Local Coverage Documents N/A
Related National Coverage Documents N/A
Public Version(s) Updated on 01/05/2016 with effective dates 10/01/2015 - N/A Updated on 11/19/2015 with
effective dates 10/01/2015 - N/A Updated on 10/14/2015 with effective dates 10/01/2015 - N/A Updated on
03/04/2015 with effective dates 10/01/2015 - N/A Updated on 07/01/2014 with effective dates 10/01/2015 - N/A
Updated on 04/02/2014 with effective dates 10/01/2015 - N/A Back to Top
Keywords
N/A Read the LCD Disclaimer Back to Top
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