• Academy Pursues Fix to Medicare’s Denial of Many Vitrectomy Procedures


    Update, March 5, 2018: CMS has officially posted an updated policy clearly stating that the previous deletion of diagnoses codes associated with national coverage decisions for vitrectomy procedures are halted. 

    Jan. 10, 2018 update:

    The Academy received word directly from the Centers for Medicare & Medicaid Services that the agency will instruct its contractor to restore recently eliminated diagnoses codes associated with national coverage decisions for vitrectomy procedures. The Academy led a successful effort to reverse this deletion, which took place in October.

    Original story:

    The Academy is fighting the recent elimination of diagnoses codes associated with national coverage decisions for vitrectomy procedures. The Academy has discussed the issue with carrier medical directors around the country. We’ve also reached out directly to the Centers for Medicare & Medicaid Services to get an explanation and ensure it corrects this error. While we seek a fix, the Academy recommends that physicians hold claims for the affected codes until a resolution is reached. 

    CMS authorized deletion of nearly 25 percent of vitrectomy’s diagnoses codes, including those for vitreous hemorrhage, macular hole and macular pucker. The deletions were part of an effort to clean up its volume of ICD-10 codes associated with national coverage decisions. 

    Still, the sheer number of diagnoses deleted is a shocking and perplexing development. The Academy remains diligent in efforts to ensure continued access to procedures often done on an emergency basis. 

    Affected codes

    E10.3591 - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

    E10.3592 - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

    E10.3593 -

    Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

     

    E11.3511 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

    E11.3512 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

    E11.3513 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

    E11.3591 - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

    E11.3592 - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

    E11.3593 - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

    E13.3511 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

    E13.3512 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

    E13.3513 - Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

     

    E13.3591 - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

    E13.3592 - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

    E13.3593 - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

     

    E08.36 - Diabetes mellitus due to underlying condition with diabetic cataract

    E09.36 - Drug or chemical induced diabetes mellitus with diabetic cataract

    E10.36 - Type 1 diabetes mellitus with diabetic cataract

    E11.36 - Type 2 diabetes mellitus with diabetic cataract

    E13.36 - Other specified diabetes mellitus with diabetic cataract

    E11.39 - Type 2 diabetes mellitus with other diabetic ophthalmic complication

    H25.091 - Other age-related incipient cataract, right eye (Coronary; Punctate age-related cataract, Water clefts)

    H25.092 - Other age-related incipient cataract, left eye (Coronary; Punctate age-related cataract, Water clefts)

    H25.093 - Other age-related incipient cataract, bilateral (Coronary; Punctate age-related cataract, Water clefts)

    H33.011 - Retinal detachment with single break, right eye

    H33.012 - Retinal detachment with single break, left eye

    H33.013 - Retinal detachment with single break, bilateral

    H33.021 - Retinal detachment with multiple breaks, right eye

    H33.022 - Retinal detachment with multiple breaks, left eye

    H33.023 - Retinal detachment with multiple breaks, bilateral

    H33.031 - Retinal detachment with giant retinal tear, right eye

    H33.032 - Retinal detachment with giant retinal tear, left eye

    H33.033  - Retinal detachment with giant retinal tear, bilateral

    H33.041 - Retinal detachment with retinal dialysis, right eye

    H33.042 - Retinal detachment with retinal dialysis, left eye

    H33.043 - Retinal detachment with retinal dialysis, bilateral

    H33.051 - Total retinal detachment, right eye

    H33.052 - Total retinal detachment, left eye

    H33.053 - Total retinal detachment, bilateral

     

    H33.331 - Multiple defects of retina without detachment, right eye

    H33.332 - Multiple defects of retina without detachment, left eye

    H33.333 - Multiple defects of retina without detachment, bilateral

    H33.8 -  - Other retinal detachments

    H35.341 - Macular cyst, hole, or pseudohole, right eye

    H35.342 - Macular cyst, hole, or pseudohole, left eye

    H35.343 - Macular cyst, hole, or pseudohole, bilateral         

    H35.371 - Puckering of macula, right eye

    H35.372 - Puckering of macula, left eye

    H35.373 - Puckering of macula, bilateral

     -

    H40.831 - Aqueous misdirection, right eye (Malignant glaucoma)

    H40.832 - Aqueous misdirection, left eye (Malignant glaucoma)

    H40.833 - Aqueous misdirection, bilateral (Malignant glaucoma)

     -

     

    H43.311 - Vitreous membranes and strands, right eye

    H43.312 - Vitreous membranes and strands, left eye

    H43.313 - Vitreous membranes and strands, bilateral

     

    H43.821 - Vitreomacular adhesions, right eye (Vitreomacular traction)

    H43.822 - Vitreomacular adhesions, left eye (Vitreomacular traction)

    H43.823 - Vitreomacular adhesions, bilateral (Vitreomacular traction)

    H43.11 -  - Vitreous hemorrhage, right eye

    H43.12 -  - Vitreous hemorrhage, left eye

    H43.13 -  - Vitreous hemorrhage, bilateral

    H43.21 -  - Crystalline deposits in vitreous body, right eye

    H43.22 -  - Crystalline deposits in vitreous body, left eye

    H43.23 -  - Crystalline deposits in vitreous body, bilateral

     -

    H43.391 - Other vitreous opacities, right eye (Vitreous floaters)

    H43.392 - Other vitreous opacities, left eye (Vitreous floaters)

    H43.393 - Other vitreous opacities, bilateral (Vitreous floaters)

     

    H59.091 - Other disorders of the right eye following cataract surgery

    H59.092 - Other disorders of the left eye following cataract surgery

    H59.093 - Other disorders of the eye following cataract surgery, bilateral

    H59.88 -  - Other intraoperative complications of eye and adnexa, not elsewhere classified

    H59.89 -  - Other postprocedural complications and disorders of eye and adnexa, not elsewhere classified

    Q14.0 -  - Congenital malformation of vitreous humor (Congenital vitreous opacity)

     

    T85.21XA - Breakdown (mechanical) of intraocular lens, initial encounter

     -

    T85.22XA - Displacement of intraocular lens, initial encounter

     -

    T85.29XA - Other mechanical complication of intraocular lens, initial encounter