L29308-LCD

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Local Coverage Determination (LCD) for Visual Field Examinations (L29308)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29308

LCD Title

Visual Field Examinations

Contractor's Determination Number 92081

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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. 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-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

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

Indications and Limitations of Coverage 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 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 that the stabilization or progression of glaucoma can be monitored only by a visual field examination, and the frequency of such examinations is dependent on the variability of intraocular pressure measurements (i.e., progressive increases despite treatment indicate a worsening condition), the appearance of new hemorrhages, and progressive cupping of the optic nerve.

• 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 that 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.

• The patient has 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 or/and stenosis of cerebral and precerebral arteries, a recently diagnosed transient cerebral ischemia or giant cell arteritis.

• The patient 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.”

• 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 (i.e., 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 that 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.

• Repeat visual field examinations for patients undergoing surgery of the upper eyelid(s) and brow (see LCD L29301 FL part B; L29485 PR/VI part B) are considered reasonable and medically necessary. The initial (taped) and repeat (untaped) visual field examination should be performed on the same date of service.

• The patient is receiving or has completed treatment of a high-risk medication that may cause visual side effects, (i.e., a patient on plaquenil may develop retinopathy).

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.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

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; 92082 INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR

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, 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

094.81 - 094.89 opens

in new window SYPHILITIC ENCEPHALITIS - OTHER SPECIFIED NEUROSYPHILIS

095.8 OTHER SPECIFIED FORMS OF LATE SYMPTOMATIC SYPHILIS

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

192.1 MALIGNANT NEOPLASM OF CRANIAL NERVES

192.2 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

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

225.1 BENIGN NEOPLASM OF CRANIAL NERVES

227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

234.0 CARCINOMA IN SITU OF EYE

237.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

237.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND

237.70 NEUROFIBROMATOSIS UNSPECIFIED

237.73 SCHWANNOMATOSIS

237.79 OTHER NEUROFIBROMATOSIS

239.7 NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM

239.81 - 239.89 NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID - NEOPLASMS OF

UNSPECIFIED NATURE, OTHER SPECIFIED SITES

242.00 - 242.01 TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC DIFFUSE

GOITER WITH THYROTOXIC CRISIS OR STORM

242.10 - 242.11 TOXIC UNINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC

UNINODULAR GOITER 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

282.60 - 282.69

DEFICIENCY SICKLE-CELL DISEASE UNSPECIFIED - OTHER SICKLE-CELL DISEASE WITH CRISIS

300.11 CONVERSION DISORDER

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 360.00 - 360.9 PURULENT ENDOPHTHALMITIS UNSPECIFIED - UNSPECIFIED DISORDER OF GLOBE

361.00 - 361.9 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - UNSPECIFIED RETINAL DETACH

362.01 -

362.07* opens in new window

362.10 - 362.18 BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA

BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS

362.21 RETROLENTAL FIBROPLASIA

362.29 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

362.81 - 362.89 INVOLVING BRUCH'S MEMBRANE RETINAL HEMORRHAGE - OTHER RETINAL DISORDERS

362.9 UNSPECIFIED RETINAL DISORDER 363.00 - 363.9 FOCAL CHORIORETINITIS UNSPECIFIED - UNSPECIFIED DISORDER OF CHOROID

364.00 - 364.9 opens in new window

ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY

365.00 - 365.06 PREGLAUCOMA UNSPECIFIED - PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA

365.10 - 365.15 DAMAGE OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.20 - 365.24 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-

CLOSURE GLAUCOMA

365.31 - 365.32 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE - CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.41 - 365.44 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED

365.51 - 365.59WITH SYSTEMIC SYNDROMES PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 - 365.65 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA

365.81 - 365.89 ASSOCIATED WITH OCULAR TRAUMA HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA 366.00 - 366.9 NONSENILE CATARACT UNSPECIFIED - UNSPECIFIED CATARACT

AMBLYOPIA UNSPECIFIED - UNSPECIFIED VISUAL DISTURBANCE

368.00 - 368.9 opens in new window

369.00 - 369.9 opens in new window

370.00 - 370.9 BLINDNESS OF BOTH EYES IMPAIRMENT LEVEL NOT FURTHER SPECIFIED - UNSPECIFIED VISUAL LOSS

CORNEAL ULCER UNSPECIFIED - UNSPECIFIED KERATITIS

371.00 - 371.9 CORNEAL OPACITY UNSPECIFIED - UNSPECIFIED CORNEAL DISORDER

373.00 - 373.02 BLEPHARITIS UNSPECIFIED - SQUAMOUS BLEPHARITIS

373.11 - 373.13 HORDEOLUM EXTERNUM - ABSCESS OF EYELID

373.2 CHALAZION

373.31 - 373.34 ECZEMATOUS DERMATITIS OF EYELID - DISCOID LUPUS ERYTHEMATOSUS OF EYELID

373.8 OTHER INFLAMMATIONS OF EYELIDS

373.9 UNSPECIFIED INFLAMMATION OF EYELID 374.00 - 374.9 ENTROPION UNSPECIFIED - UNSPECIFIED DISORDER OF EYELID

376.00 - 376.9 ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - UNSPECIFIED DISORDER OF ORBIT

377.00 - 377.9 opens in new window

378.00 - 378.9 PAPILLEDEMA UNSPECIFIED - UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS

ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE MOVEMENTS

379.50 - 379.59 NYSTAGMUS UNSPECIFIED - OTHER IRREGULARITIES OF EYE MOVEMENTS

379.92 SWELLING OR MASS OF EYE

431 INTRACEREBRAL HEMORRHAGE

432.0 - 432.9 NONTRAUMATIC EXTRADURAL HEMORRHAGE - UNSPECIFIED INTRACRANIAL HEMORRHAGE

433.00 - 433.91 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION -OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL NFARCTION

434.00 - 434.91 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY

435.0 - 435.9 OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

437.0 - 437.9 CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR DISEASE

446.5 GIANT CELL ARTERITIS

743.20 - 743.22 BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES

743.51 - 743.59 VITREOUS ANOMALIES CONGENITAL - OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT

743.61 - 743.69 CONGENITAL PTOSIS OF EYELID - OTHER CONGENITAL ANOMALIES OF EYELIDS

921.0 - 921.9 LACRIMAL SYSTEM AND ORBIT

BLACK EYE NOT OTHERWISE SPECIFIED - UNSPECIFIED CONTUSION OF EYE

930.0 - 930.9 CORNEAL FOREIGN BODY - FOREIGN BODY IN UNSPECIFIED SITE ON EXTERNAL EYE

950.0 - 950.9 OPTIC NERVE INJURY - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS

951.0 INJURY TO OCULOMOTOR NERVE

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

* According to the ICD-9-CM book, diagnosis code V58.69 is a secondary diagnosis code and should not be billed as the primary diagnosis.

* ICD-9-CM code 362.07 requires a dual diagnosis. When using ICD-9-CM 362.07 (diabetic macular edema) a code for diabetic retinopathy (362.01-362.06) must also be used.

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

Medical record documentation must indicate the medical necessity for performing the test. In addition, documentation that the service was performed including the results of the Visual Field Examination should be available. This information is normally found in the office notes, progress notes, history and physical, and/or hard copy of the test results.

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.

Appendices

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 1998 Physician Desk Reference

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from The Ophthalmology Society.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 5

Revision History Explanation Revision Number:5 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added ICD-9-CM codes 365.05 and 365.06. Deleted diagnosis code range 365.00-365.9 and replaced with specific diagnosis code ranges (new diagnosis codes 365.70

-365.74 were not added to LCD). The effective date of this revision is based on date of service.

Revision Number:4

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Added diagnosis code 237.73 and 237.79 and descriptor. The effective date of this revision is based on date of service.

Revision Number:3

Start Date of Comment Period:N/A Start Date of Notice Period:12/01/2009 Revised Effective Date: 11/03/2009

LCR B2009-102

November 2009 Update

Explanation of Revision: Revised the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD to include repeat visual field examination when performed on the same date of service as being reasonable and medically necessary. The effective date of this revision is based on process date.

10-19-2009 - Corrected effective date for revision #1 to be 10/26/2009 (not 10/23/2009). Revision Number:2

Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Deleted diagnosis code 239.8 and replaced with diagnosis code range 239.81-239.89. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:11/01/2009 Revised Effective Date: 10/26/2009

LCR B2009-097

October 2009 Update

Explanation of Revision: Added dual diagnosis requirement for ICD-9-CM code 362.07 under the “ICD-9 Codes that Support Medical Necessity” section of the LCD. The effective date of this revision is for claims processed on or after 10/26/2009 for dates of service on or after 10/01/2005.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL

December 2008 Update

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29308) replaces LCD L6724 as the policy in notice. This document (L29308) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

92083 descriptor was changed in Group 1

Reason for Change