E/M CODES | Evaluation & Management

92-"Routine" Exam Codes

92-Routine Exam Codes
92002 Intermediate Exam, New patient

Medical examination and evaluation with initiation of diagnostic treatment program

92004 Comprehensive Exam, New patient

Medical examination and evaluation with initiation of diagnostic treatment program;

92012 Intermediate Exam, Established patient

Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program;

92014 Comprehensive Exam, Established patient

Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program;

S0620 Comprehensive exam, New patient
S0621 Comprehensive exam, Established patient

99-Telehealth Virtual Visits

Telehealth

 

99202 -95 Mod Level 2: New patient Medical (Straightforward) Telehealth 

Evaluation and management; Expanded problem-focused history; Straightforward

99203 -95 Mod Level 3: New patient Medical (Low Complexity) Telehealth

 Evaluation and management; Detailed history; Low complexity; Moderate severity

99212-95 Mod Level 2: Established patient Medical (Straightforward)  Telehealth 

Evaluation and management; Problem-focused history; Straightforward; Self-limited or minor severity

99213 -95 Mod Level 3: Established patient Medical (Low Complexity) Telehealth 

Evaluation and management; Expanded problem-focused history; Low complexity; Low to moderate severity

Use -95 Mod and bill 99-Code based on medical decision-making (not time spent). Need Real-Time Interactive Audio and Video Telecommunications. 

 

99-Office Visit Medical Codes

99-Office Visit Medical Codes
99202 Level 2: New patient Medical OV (Straightforward)

Evaluation and management; Expanded problem-focused history; Straightforward

99203 Level 3: New patient Medical OV (Low Complexity)

Evaluation and management; Detailed history; Low complexity; Moderate severity

99204 Level 4: New patient Medical OV (Mod Complexity)

Evaluation and management; Comprehensive history; Moderate complexity; Moderate to high severity

99205 Level 5: New patient Medical OV (Highest Complexity)

Evaluation and management; Comprehensive history; High complexity; Moderate to high severity

 

99212 Level 2: Established patient Medical OV (Straightforward)

Evaluation and management; Problem-focused history; Straightforward; Self-limited or minor severity

99213 Level 3: Established patient Medical OV (Low Complexity)

Evaluation and management; Expanded problem-focused history; Low complexity; Low to moderate severity

99214 Level 4: Established patient Medical OV (Mod Complexity)

Evaluation and management; Detailed history; Moderate complexity; Moderate to high severity

99215 Level 5: New patient Medical OV (Highest Complexity)

Evaluation and management; Comprehensive history; High complexity; Moderate to high severity

99- Emergency Hours

99- Emergency Hours
99050 After hours
99051  During scheduled evenings & weekends
99058 During normal hours disrupting schedule
99060 Out of Office, disrupts schedule
You will likely never get paid for this by insurances, so consider pay private 

CPT PROCEDURES

REFRACTION | CONTACT LENS FIT

REFRACTION CONTACT LENS FIT
92015 Refraction and any necessary prescription of lenses
Medical: You are performing 92015 in order to determine the BVCA and is used as a metric for assessing the medical condition and should be tied to medical DX code (NOT a refractive code). 
92310 Fitting of contact lens

FITTING THERAPEUTIC | BANDAGE CONTACT LENS

FITTING THERAPEUTIC BANDAGE CONTACT LENS
92071 Fitting of contact lens for treatment of ocular surface disease (unilateral)


Need -RT or -LT modifer 

99070 Supplies and materials [except spectacles]


Initially can be used for supply of the BCL itself but it is commonly rejected, so useless to bill it along with 92071 & 92072

 

KERATOCONUS

KERATOCONUS
92072 Fitting of a contact lens for the management of keratoconus (initial fitting) 
V2513 Contact lens, gas permeable, extended wear, per lens 
V2531  Contact lens, scleral, gas permeable, per lens
*Use -22 modifier (increased procedural circumstances) which indicate KCN fitting for V2513 or V2531 


*Most medical insurance will not cover contact lens services. In that case, it is permitted for you to bill the patient directly for your exam fees and CL materials.  

 

COLOR VISION

COLOR VISION
92283 (IR) Color vision examination, extended, e.g., anomaloscope or equivalent)
Commonly used to monitor high-risk meds like Plaquenil, but also on congenital or acquired color defects for optic nerve conditions like glaucoma.


Clinical Tool: Check these free interactive online tests 

FOREIGN BODY REMOVALS

FOREIGN BODY REMOVALS
65205 Conjunctival, superficial, removal of foreign body, externally 
65210 Conjunctival, embedded, removal of foreign body, externally
65220 Corneal, without slit lamp, Removal of foreign body, externally
65222 Corneal, with slit lamp, removal of foreign body, externally 
Use -25 Modifier on exam code. Use RT/LT. No global periods

DILATION | IRRIGATION

DILATION IRRIGATION
68800 Dilation of lacrimal punctum, with or without irrigation, unilateral or bilateral
68820 Probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral

2022: Both procedures are bilateral, use -50 modifier. No global periods


DO NOT bill both probing & dilation together

 

DRAINAGE OF HORDELUM | CHALAZION

DRAINAGE OF HORDELUM CHALAZION
11440 Drainage of Benign Eyelid Cyst (Hordelum or Chalazion) 
Depending on the size of lesion, code will range 11440-11446,  unilateral code (billed per eye, and not per eyelid) and requires a lid modifier (E1, 2,3,4). Add on a mod -25 on exam code if you just performed one.  10 days global period 
67800 (Excision of chalazion) or 67840 (excision of eyelid) is more invasive procedures compared to the skin/lesion portion with 11440 (drainage)  

AMNIOTIC MEMBRANE

AMNIO
65778 Placement of Amniotic Membrane of Ocular Surface 
Requires -RT and -LT eyelid modifiers, include the cost of the actual amniotic membrane. No global period 

PUNCTAL PLUGS | DRY EYES

PUNCTAL PLUGS DRY EYES
68761 Closure of the lacrimal punctum; by plug, each

10 day post-op period on all plugs. Medicare requires a h/o of prior TX of dry eyes before plugs. 

Occluded One lid  68761
Occluded Both lids 

68761 E2

68761 -51 mod E4

Occluded Both Upper  lids 

68761 E1

68761 -51 mod E3

Occluded All 4 eyelid 

68761 E1

68761 -51 mod E2

68761 -51 mod E3

68761 -51 mod E4

Occluded BOTH eyelids

RE: 68761 E3                

LE:  68761 E1

Same Eye

RE: 68761 -51 mod E4         

LE: 68761 -51 mod E2    

CORNEAL SCRAPE | EPILATION | MGD

CORNEAL SCRAPE EPILATION MGD
65435 Removal of corneal epithelium
67820 Epilation, by forceps only. Correction of trichiasis

0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral
0330T (IR)  Tear film imaging, unilateral or bilateral, with interpretation and report
0507T (IR) Near infrared dual imaging of meibomian glands, unilateral or bilateral, with interpretation and report
0563T Evacuation of meibomian glands, using heat delivered through wearable, open eye eyelid treatment devices and manual gland expression, bilateral

EXTERNAL | FUNDUS PHOTOS

EXTERNAL FUNDUS PHOTOS
92285 (IR)  External ocular photography 
If doing only 1 eye, add for -52 mod for reduced service. 

 

92250 (IR)  Fundus photography with interpretation and report 
If doing only 1 eye, add for -52 mod for reduced service. DO NOT bill screening photos or wellness photos, those should be private pay S9986 

 

OCT SCAN

OCT
92132 (IR)  OCT Anterior Segment | Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
92133 (IR) OCT Optic Nerve | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
92134 (IR) OCT Retina/Macula  |Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
S9986  OCT Screener |  Non-medically necessary screening  
92132 OCT Corneal Corneal Thickness. DX code not covered, need to do actual corneal pachymetry 76514. Might be used for CL fitting instead 

You cannot bill fundus photo (92250) and OCT at the same visit 

Mild Glaucoma: 1 OCT max per year 

Moderate Glaucoma: 2 OCT max  per year

Advanced Glaucoma: rarely necessary or beneficial 

Retina disorders: 4 OCT max per year 

Macular Degeneration: 1 OCT per eye, per month

 

VISUAL FIELD

VISUAL FIELD
92081 (IR)  Limited Visual field Exam. Unilateral or bilateral,  with interpretation and report 
92082 (IR)  Intermediate Visual field Exam. Unilateral or bilateral,  with interpretation and report
92083 (IR)  Extended Visual field Exam. Unilateral or bilateral,  with interpretation and report

Mild Glaucoma (good control): 1 VF max per year 

Mild | Moderate | Advanced Glaucoma (borderline controlled): 2 VF max  per year

Uncontrolled Glaucoma: 4 VF max per year 

GONIO | CORNEAL PACHYMETRY

GONIO CORNEAL PACHYMETRY
92020 (IR)  Gonioscopy 
If performing on 1 eye only, use -52 mod 
76514 Corneal Pachymetry, unilateral or bilateral

Glaucoma | OHT: Only once per lifetime, can be billed same day as VF and OCT  

Corneal Disease: As needed 

 

92100 (IR) Serial Tonometry 
Service are billed bilateral regardless if only 1 eye or both eyes are tested 

 

 

CORNEAL TOPOGRAPHY | A/B-SCAN

B SCAN
92025 (IR)  Corneal Topography 
76511 (IR)  Ophthalmic Ultrasound, echography, diagnostic (A-Scan only) with amplitude quantification  
76519 Ophthalmic Biometry by Ultrasound (A-Scan). 

Need -RT or -LT mod since it is unilateral code 

76512 Ophthalmic Ultrasound B-Scan (Standard)

Need -RT, -LT or -50 if performed bilaterally 

76513 Ophthalmic Ultrasound B-Scan (High Resolution UBM)

Need -RT, -LT or -50 mod if performed bilaterally 

76510 (IR)  Ophthalmic Ultrasound, diagnostic : B-Scan & quantitative A-scan performed during the SAME VISIT 

Both A-Scan & B-Scan at Same Visit 

 

EXTENDED OPHTHALMOSCOPY

EXTENDED OPHTHALMOSCOPY
92201(IR)  Peripheral retinal disease DFE & drawing of fundus 

Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral


*No modifier needed 

92202 (IR)

Optic Nerve or Macula DFE & drawing of funds 

Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral and bilateral.

92201/92202 is the most heavily audited CPT code since it is not a simple routine dilation but include IR and drawing 

 

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MODIFIERS

-RT Right eye
-LT Left eye
-E1 Upper left eyelid
-E2 Lower left eyelid
-E3 Upper right eyelid
-E4 Lower right eyelid
-GY Non-covered service under Medicare
-TC Technical component. Ex: You are doing the VF for another doctor to interpret 
-Q6 Locums Tenens: A fill-in doctor take over an absent doctor for 60 days or less. 
-22  Increased procedural circumstances
-24 Unrelated E/M by same doctor during postoperative period
-25 Separately identifiable E/M service provided by the same doctor on the same day as another procedure
-26 Professional component only. Ex: Another OD performs a OCT but you do the IR report 

 

-50 Bilateral procedure
-51 Multiple procedures performed on the same day during the same encounter
-52 Reduced service
-54 Surgical component only
-55 Post operative management only (Co-management code) 
-59 Distinct procedure service identifies procedures/services not normally reported together but appropriately billed under the circumstances
-79 Unrelated procedures or service by same doctor during the postoperative period
-95 Telemedicine 

ICD-10 DIAGNOSIS CODES

VISION | SYMPTOMS

1, 2, 3 = R, L, B
VISION SYMPTOMS
Amblyopia Deprivation H53.01___
Amblyopia Refractive H53.02___
Amblyopia Strabismus  H53.03___
Amblyopia Unspecified H53.00 ___
Aniseikonia H52.32
Anisometropia H52.31

 

Visual discomfort(asthenopia) H53.14
Visual distortions of shape  H53.15
Visual disturbance (Psych)  H53.16
Visual disturb (subjective)  H53.19
Visual loss (Sudden) H53.13___
Visual loss (Transient) H53.12___ 

 

VF Arcuate/Sector H53.43___
VF Central/Paracentral  H53.41___
VF Constriction (general) H53.48___
VF homonymous R.Side H53.461
VF homonymous L.Side H53.462
VF heteronymous bilateral  H53.47
VF other localized defects H53.45___

 

Ocular Pain H57.1___  
Photopsia H53.19

 

Astigmatism, regular H52.22 ___
Hyperopia (hypermetropia)  H52.0___
Presbyopia H52.4
Myopia H52___
Degenerative/Malignant Myopia H44.2___

 

Color vision deficiencies 
  • Achromatopsia 
H53.51
  • Acquired color vision defect 
H53.52
  • Deuteranomaly
H53.53
  • Protanomaly 
H53.54
  • Tritanomaly 
H53.55
  • Other
H53.59
  • Unspecified
H53.50

 

STRABISMUS | ORBIT

1, 2 = R, L
STRABISMUS ORBIT
Diplopia H53.2
Convergence disorder (Insuff) H51.11
Convergence disorder (Excess) H51.12
Esophoria H50.51
Esotropia
  • Alternating 
H50.05
  • Intermittent, alternating
H50.32
  • Monocular (RE | LE)
H50.31___
  • Intermittent, monocular
H50.01___          
Exophoria  H50.52
Exotropia
  • Alternating
H50.15
  • Intermittent, alternating
H50.34
  • Monocular Exotropia
H50.11___
  • Intermittent, monocular
H50.33___  
Hyper | Hypotropia strabismus  H50.2___ 
Duane's syndrome H50.81___

 

Cellulitis, orbital  H05.01
Exophthalmos (unspecified) H05.20

 

NEURO | HEADACHE

1, 2 = R, L
NEURO
3rd CN  palsy H49.0___
4th CN palsy H49.1___
6th CN palsy H49.2___
Bell’s palsy (7th CN) G51.0
 
Nystagmus (Congenital) H55.01
Nystagmus (Latent) H55.02
Nystagmus (Others) H55.09
Cortical Blindness H47.61___
Headache Orthostatic (not classified) R51.0
Headache (Unspecified) R51.9
 
Headache (Tension-type)
  • Chronic: Intractable
G44.221
  • Chronic: NOT intractable
G44.229
  • Episodic: Intractable
G44.211 
  • Episodic:  NOT intractable
G44.219
  • Unspecified: Intractable
G44.201 
  • Unspecified: NOT intractable
G44.209
 
Headache (Migraine)
  • Aura, not-intract, no migra
G43.109
  • Aura, not-intract, migra
G43.101
  • Aura, Intract, migra
G43.111
  • Aura, Intract, no migra
G43.119
  • Ophthalmoplegic, migra
G43.B0
  • Ophthalmoplegic, no migra
G43.B1

 

LASHES | EYELID | LACRIMAL

1= RUL, 2=RLL, 4=LUL, 5=LLL, A= R Both Lids, B= L Both Lids
LASHES EYELID LACRIMAL LASHES
Blepharitis (Ulcerative) H01.01___
Blepharitis (Squamous) H01.02___
Blepharitis (Unspecified)  H01.00___
Blepharitis (Unspecified) H01.009
Lagophthalmos, unspecified H02.20___
Lagophthalmos, unspecified (OU) H02.20C
Meibomian gland dysfunction H02.88___
Meibomian gland dysf (Unspec) H02.88

1= RUL, 2=RLL, 4=LUL, 5=LLL

Blepharochalasis | pseudoptosis H02.3___
Cellulitis, Preseptal  H00.03___
Chalazion H00.1___
Chalazion Unspecified H00.19
Dermatochalasis H02.83___
Dermatochalasis Unspecified H02.839
Edema of eyelid H02.84___
Ectropion (Cicatricial) H02.11___
Ectropion (Mechanical) H02.12___
Ectropion (Senile) H02.13___
Ectropion (Spastic) H02.14___
Ectropion (Unspecified) H02.10___
Entropion (Cicatricial) H02.01___
Entropion (Mechanical) H02.02___
Entropionn (Senile) H02.03___
Entropion (Spastic) H02.04___
Entropion (Unspecified) H02.00___
Hordeolum Externum  H00.01___
Hordeolum Internum  H00.02___
Trichiasis, without entropion  H02.05___
Xanthelasma of eyelid  H02.6___

1,2,3= R, L, B

Dacryoadenitis (unspecified)

H04.00___

Dacryocystitis (unspecified)

H04.30___

Dry eye syndrome

H04.12___

Epiphora (Excess tears) 

H04.21___

Epiphora (Insuff drain of tears)

H04.22___

Inflammation of eyelid (Other)

H01.8

Inflammation of eyelid (Unspecified)

H01.9

Nasolacr duct obstruct (Acquir)

H04.55___

Ptosis Congenital

Q10.0

Ptosis (Mechanical)

H02.41___

Ptosis (Myogenic)

H02.42___

Ptosis (Paralytic)

H02.43___

Ptosis (Unspecified)

H02.40___

Punctal stenosis

H04.56___

Stenosis of lacrimal punctum

H04.56___

Papilloma (squam) (OD/OS)

D23.11 / D23.12

Skin Tag

L91.8

 

 

CONJUNCTIVA | SCLERA

1, 2, 3 = R, L, B
CONJUNCTIVA SCLERA

 

Chemosis  H11.42
Conjunctivitis (Acute) 
  • Atopic (allergic) 
H10.1___
  • Follicular
H10.01___
  • Toxic (chemical)
H10.21___
  • Unspecified
H10.3___
 
Conjunctivitis (Chronic)
  • Allergic

 

H10.45
  • Giant Papillary (GPC)

 

H10.41___
  • Follicular
H10.43___
  • Simple
H10.42___
  • Unspecified

 

H10.40___
 
Conjunctivitis (Muropur | Bacterial) H10.02___
Conjunctivitis (vernal) H10.44
Other Conjunctivitis H10.89
Conjunctival Cyst  H11.44___
Conjunctival Hyperemia H11.43___
Conjunctival Neoplasm D31.0___
Episcleritis (Unspecified) H15.10___
Episcleritis (Nodular) H15.12___
Episcleritis H15.11___
Pinguecula  H11.15___
Pingueculitis  H10.81___
Subconj heme H11.3___
Scleritis (Unspecified) H15.00___
Scleritis (Anterior) H15.01___

 

CONJUNCTIVA + CORNEA ABRASION

CONJUNCTIVA + CORNEA ABRASION

1,2 =R,L         A,D=1st, FU

 

Conj Abrasion, no FB S05.0___X____
Conj Foreign Body   TI5.1___X ____
 
Cornea Abras, no FB S05.0___X___
Cornea Foreign Body  T15.0___X ___
Corneal Burn/Chemical T26.1___X___

CORNEA

1, 2, 3 = R, L, B
CORNEA

 

Arcus H18.41___
Band keratopathy H18.42___
Bullous keratopathy H18.1___
Degeneration, cornea H18.49
Edema cornea (unspec) H18.20
Endo dystrophy (Fuchs) H18.51___
Guttata (cornea) H18.51
Keratitis
  • Dendritic (H. simplex)
B00.52
  • Dendritic (H. zoster)
B02.33
  • Exposure (SPK)
H16.21___
  • Filamentary
H16.12___
  • Interstitial (diffuse)
H16.32___
  • Punctate (SPK)
H16.14___
  • Unspecified
H16.10___
  • Other
H16.8
 
Keratoconjunctivitis, other H16.29___
Keratoconjunctivitis (non-Sjögren) H16.22___
Keratoconus
  • Stable
H18.61___
  • Unstable
H18.62___
  • Unspecified
H18.60___
 
Neovascularization, cornea
  • Ghost vessels 
H16.41___
  • Pannus
H16.42___
  • Unspecified
H16.40___
Opacities, cornea
  • Central
H17.1___
  • Minor
H17.81___
  • Peripheral
H17.82___
  • Other scars and opacities
H17.89
 
Pannus, cornea H16.42___
Pterygium
  • Central
H11.02___
  • Peripheral, progressive
H11.05___
  • Peripheral, stationary
H11.04___
  • Recurrent
H11.06___
  • Unspecified
H11.00___
Recurrent erosion, cornea H18.83___
Transplant, cornea
  • Rejection
T86.840
  • Failure
T86.841
  • Infection
T86.842
  • Other complications 
T86.848
 
Ulcer, cornea
  • Central
H16.01___
  • Marginal
H16.04___
  • Unspecified
H16.00___

 

 

IRIS

1, 2 ,3 =R, L, B
IRIS
Angle Recession H21.55___
Floppy iris syndrome H21.81
Hyphema Non-traumatic H21.0___

 

Hyphema Traumatic 
ODinitial / subq S05.11XA / S05.11XD
OSinitial / subq S05.12XA / S05.12XD
Iridodialysis H21.53___
Iris bombé  H21.4___
Plateau iris syndrome H21.82
Iritis Acute Primary  H20.01___
Iritis Recurring Primary H20.02___

LENS | CATARACTS

1, 2 ,3 =R, L, B
LENS CATARACTS

 

Aphakia (acquired) H27.0___
After Cataract (PCO) H26.49___
Cataract, age-related (senile)
  • Combined
H25.81___
  • Cortical
H25.01___
  • Hypermature (Morgagnian)
H25.2___
  • Nuclear
H25.1___
  • Mature
H25.89
  • Post supcap (PSC)
H25.04___
Cataract (congenital) Q12.0
Cataract (diabetic) E11.36
Cataract (traumatic) H26.13___

 

Dislocated (Subluxed Lens) H27.11___
Pseudophakia  Z96.1

 

VITREOUS

1, 2 ,3 =R, L, B
VITREOUS (2)

 

Asteroid hyalosis H43.2___
Vitreous Deg (PVD) H43.81___
Vitreous Floaters H43.39___
Vitreous hemorrhage H43.1___
Vitreous Prolapse H43.0___
Vitreous Membranes | Strands H43.31___
Vitreous (Other opacities) H43.39___
 
Vitreomacular adhesion H43.82___

 

MACULA

1, 2 ,3 =R, L, B
MACULA (1)

 

Macular drusen H35.36___
Macular hole,cyst, pseudo H35.34___
Macular pucker (ERM) H35.37___
Unspecified Macular Degen H35.30
Central Macular Edema H35.35___
Central Serous Ret (CSR) H35.71___
C/R Scar (Macula, Retina) 
  • Unspecified
H31.00___
  • Other
H31.09___
Cystoid macular edema (PostSur) H59.03___
Retinal Edema H35.81
Toxic maculopathy H35.38___
Solar Retinopathy H31.02___

 

1, 2, 3 = R, L/,B

0, 1, 2, 3, 4 = Unspec, Early, Inter, Adv Atrophic w/o subfoveal, Adv Atrophic w/subfoveal

Macular degeneration (Dry) H35.31___  ____

 

1, 2, 3 =R, L, B

0, 1, 2, 3 = Unspec, Active CVM, inactive CVM, Inactive Scar

Macular degeneration (Wet) H35.32___  ____

 

OPTIC NERVE

1, 2 ,3 =R, L, B
Optic Nerve

 

Drusen of ONH H47.32___
Ischemic optic (AION)   H47.01___
 
Optic Atrophy (Primary)  H47.21___
Optic Atrophy (Partial)    H47.29___
Optic Neuritis, papillitis  H46.0___
 
Papilledema, PTC H47.11
Pseudopapilledema H47.33___
Retrobulbar neuritis H46.11___

 

RETINA

1, 2 ,3 =R, L, B
RETINA
C/R Scar (Macula, Retina) 
  • Unspecified
H31.00___
  • Other
H31.09___
CHRPE  D31.2___
Choroidal Nevus D31.3___
Choroidal Melanoma C69.3___
Cotton Wool Spot (CWS) H35.81
 
Detachment, retinal
  • Partial, giant tear
H33.03___
  • Partial, multiple defects
H33.02___
  • Partial, single defect
H33.01___
  • Total (New)
H33.05___
  • Tractional
H33.4___
  • Post-Op detachment
Z98.890
  • Other RD (old)
H33.8
  • History of RD
Z86.69 
 
Tear, retinal
  • Horseshoe w/o detach
H33.31___
  • Multiple tears, w/ detach
H33.33___
  • Round hole w/o detach
H33.32___
  • History of Retina Tear
Z86.69
  • Post-Op Retinal Tear
Z98.890
 
Lattice Degeneration H35.41___
Myelinated NFL H35.89  
Myopia Degeneration H44.2___
Pavingstone degen H35.43____
Pigmentary degen H35.45____
Reticular degen H35.44___
Retinoschisis, unspecified H33.10___
Toxo, chorioretinitis   B58.01  
WWOP H35.46____
Peripheral Degen | Dursen H35.4___
Hypertensive Ret H35.03___
Branch Ret Artery Occu (BRAO) H34.23___
Branch Ret VeinOccu (BRVO) H34.83___
​​Central Ret Artery Occu  (CRAO) H34.1___

 

1, 2, 3=R,,L, B   

0, 1, 2 = Macular Edema , Retina Neo,  Stable Old CRVO

Cent RetVeinOccu (CRVO) H34.81___ ___

 

DIABETIC RETINOPTHY

1, 2, 3 = R,L, B
DIABETIC RETINOPTHY

2, 3, 4, 5 = Mild, Mod, Severe, Proliferative

DM Type 1 | Macular Edema E10.3___1___
DM type 1 | No Macular Edema E10.3___9___
DM type 1 | No Retinopathy E10.9
 
DM type 2 | Macular Edema E11.3___1___
DM type 2 | No Macular Edema E11.3___9___
DM type 2 | No Retinopathy E11.9  

 

 

GLAUCOMA SUSPECT

1, 2 ,3 =R, L, B
GLAUCOMA SUSPECT (1)

 

Degen of Iris Pigmentary (PDS) H21.23___
Glaucoma suspect
  • Open angle (Low Risk)  
H40.01___
  • Open angle (High Risk)
H40.02___
  • Anatomical narrow angle 
H40.03___
  • Steroid responder
H40.04___
Ocular Hypertension H40.05___
Glaucomatous (Physio Cupping) H47.23___

 

GLAUCOMA

1, 2 ,3 =R, L, B
GLAUCOMA

 

Angle-closure glau (acute) H40.21 ___
Angle-closure glau  (Intermit) H40.23___
Malignant glaucoma H40.83___
Congenital glaucoma Q15.0
Glaucoma (vascular )  H40.89

1, 2, 3 = R, L, B       

0,1,2,3,4 = Unspecified, Mild, Mod, Sev, Indetrm

Ang-closure glau (Chronic) H40.22___ ___
Glaucoma (2’ eye inflamm) H40.4___X___
Glaucoma (trauma) H40.3___X___
Low tension glaucoma (NTG) H40.12___ ___
Phacolytic glaucoma H40.5___X___
Pigmentary glaucoma H40.13___ ___
Primary open-angle (POAG)   H40.11 ___  ___
Pseudoexfoliation glau H40.14___ ___
 Steroid induced glaucoma H40.6___X___

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