Medicare Advantage

Medical Policy

Notification

Corneal Pachymetry Using Ultrasound

Notification Issued Date: N/A

This version of the policy will become effective 09/19/2022.

The following ICD-10 Diagnosis codes for unspecified eye have been removed from this policy:  
H18.10, H18.219, H18.229, H18.239, H18.509, H18.519, H18.529, H18.539, H18.549, H18.559, H18.599, H18.609, H18.619, H18.629, H18.719, H18.799, H21.559, H40.009, H40.019, H40.029, H40.039, H40.049, H40.059, H40.069, H40.1190, H40.1191, H40.1192, H40.1193, H40.1194, H40.1290, H40.1291, H40.1292, H40.1293, H40.1294, H40.1390, H40.1391, H40.1392, H40.1393, H40.1394, H40.1490, H40.1491, H40.1492, H40.1493, H40.1494, H40.219, H40.2290, H40.2291, H40.2292, H40.2293, H40.2294, H40.239, H40.249, H40.30X0, H40.30X1, H40.30X2, H40.30X3, H40.30X4, H40.40X0, H40.40X1, H40.40X2, H40.40X3, H40.40X4, H40.50X0, H40.50X1, H40.50X2, H40.50X3, H40.50X4, H40.60X0, H40.60X1, H40.60X2, H40.60X3, H40.60X4, H40.829, H40.839, H44.519, T86.8409, T86.8419, T86.8489, ​T86.8499​

Policy Attachment

Attachment to Policy #

MA07.046g

Attachment:

Policy #:

MA07.046g

Description:

ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound

Title:

Corneal Pachymetry Using Ultrasound

ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound


H18.11	Bullous keratopathy, right eye
H18.12	Bullous keratopathy, left eye
H18.13	Bullous keratopathy, bilateral
H18.20	Unspecified corneal edema
H18.211	Corneal edema secondary to contact lens, right eye
H18.212	Corneal edema secondary to contact lens, left eye
H18.213	Corneal edema secondary to contact lens, bilateral
H18.221	Idiopathic corneal edema, right eye
H18.222	Idiopathic corneal edema, left eye
H18.223	Idiopathic corneal edema, bilateral
H18.231	Secondary corneal edema, right eye
H18.232	Secondary corneal edema, left eye
H18.233	Secondary corneal edema, bilateral
H18.501	Unspecified hereditary corneal dystrophies, right eye
H18.502	Unspecified hereditary corneal dystrophies, left eye
H18.503	Unspecified hereditary corneal dystrophies, bilateral
H18.511	Endothelial corneal dystrophy, right eye
H18.512	Endothelial corneal dystrophy, left eye
H18.513	Endothelial corneal dystrophy, bilateral
H18.521	Epithelial (juvenile) corneal dystrophy, right eye
H18.522	Epithelial (juvenile) corneal dystrophy, left eye
H18.523	Epithelial (juvenile) corneal dystrophy, bilateral
H18.531	Granular corneal dystrophy, right eye
H18.532	Granular corneal dystrophy, left eye
H18.533	Granular corneal dystrophy, bilateral
H18.541	Lattice corneal dystrophy, right eye
H18.542	Lattice corneal dystrophy, left eye
H18.543	Lattice corneal dystrophy, bilateral
H18.551	Macular corneal dystrophy, right eye
H18.552	Macular corneal dystrophy, left eye
H18.553	Macular corneal dystrophy, bilateral
H18.591	Other hereditary corneal dystrophies, right eye
H18.592	Other hereditary corneal dystrophies, left eye
H18.593	Other hereditary corneal dystrophies, bilateral
H18.601	Keratoconus, unspecified, right eye
H18.602	Keratoconus, unspecified, left eye
H18.603	Keratoconus, unspecified, bilateral
H18.611	Keratoconus, stable, right eye
H18.612	Keratoconus, stable, left eye
H18.613	Keratoconus, stable, bilateral
H18.621	Keratoconus, unstable, right eye
H18.622	Keratoconus, unstable, left eye
H18.623	Keratoconus, unstable, bilateral
H18.70	Unspecified corneal deformity
H18.711	Corneal ectasia, right eye
H18.712	Corneal ectasia, left eye
H18.713	Corneal ectasia, bilateral
H18.791	Other corneal deformities, right eye
H18.792	Other corneal deformities, left eye
H18.793	Other corneal deformities, bilateral
H21.551	Recession of chamber angle, right eye
H21.552	Recession of chamber angle, left eye
H21.553	Recession of chamber angle, bilateral
H40.001	Preglaucoma, unspecified, right eye
H40.002	Preglaucoma, unspecified, left eye
H40.003	Preglaucoma, unspecified, bilateral
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
H40.10x1	Unspecified open-angle glaucoma, mild stage
H40.10x2	Unspecified open-angle glaucoma, moderate stage
H40.10x3	Unspecified open-angle glaucoma, severe stage
H40.10x4	Unspecified open-angle glaucoma, indeterminate stage
H40.1110	Primary open-angle glaucoma, right eye, stage unspecified
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage
H40.1114	Primary open-angle glaucoma, right eye, indeterminate stage
H40.1120	Primary open-angle glaucoma, left eye, stage unspecified
H40.1121	Primary open-angle glaucoma, left eye, mild stage
H40.1122	Primary open-angle glaucoma, left eye, moderate stage
H40.1123	Primary open-angle glaucoma, left eye, severe stage
H40.1124	Primary open-angle glaucoma, left eye, indeterminate stage
H40.1130	Primary open-angle glaucoma, bilateral, stage unspecified
H40.1131	Primary open-angle glaucoma, bilateral, mild stage
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage
H40.1133	Primary open-angle glaucoma, bilateral, severe stage
H40.1134	Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1210	Low-tension glaucoma, right eye, stage unspecified
H40.1211	Low-tension glaucoma, right eye, mild stage
H40.1212	Low-tension glaucoma, right eye, moderate stage
H40.1213	Low-tension glaucoma, right eye, severe stage
H40.1214	Low-tension glaucoma, right eye, indeterminate stage
H40.1220	Low-tension glaucoma, left eye, stage unspecified
H40.1221	Low-tension glaucoma, left eye, mild stage
H40.1222	Low-tension glaucoma, left eye, moderate stage
H40.1223	Low-tension glaucoma, left eye, severe stage
H40.1224	Low-tension glaucoma, left eye, indeterminate stage
H40.1230	Low-tension glaucoma, bilateral, stage unspecified
H40.1231	Low-tension glaucoma, bilateral, mild stage
H40.1232	Low-tension glaucoma, bilateral, moderate stage
H40.1233	Low-tension glaucoma, bilateral, severe stage
H40.1234	Low-tension glaucoma, bilateral, indeterminate stage
H40.1310	Pigmentary glaucoma, right eye, stage unspecified
H40.1311	Pigmentary glaucoma, right eye, mild stage
H40.1312	Pigmentary glaucoma, right eye, moderate stage
H40.1313	Pigmentary glaucoma, right eye, severe stage
H40.1314	Pigmentary glaucoma, right eye, indeterminate stage
H40.1320	Pigmentary glaucoma, left eye, stage unspecified
H40.1321	Pigmentary glaucoma, left eye, mild stage
H40.1322	Pigmentary glaucoma, left eye, moderate stage
H40.1323	Pigmentary glaucoma, left eye, severe stage
H40.1324	Pigmentary glaucoma, left eye, indeterminate stage
H40.1330	Pigmentary glaucoma, bilateral, stage unspecified
H40.1331	Pigmentary glaucoma, bilateral, mild stage
H40.1332	Pigmentary glaucoma, bilateral, moderate stage
H40.1333	Pigmentary glaucoma, bilateral, severe stage
H40.1334	Pigmentary glaucoma, bilateral, indeterminate stage
H40.1410	Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified
H40.1411	Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage
H40.1412	Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage
H40.1413	Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage
H40.1414	Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1420	Capsular glaucoma with pseudoexfoliation of lens, left eye, stage unspecified
H40.1421	Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage
H40.1422	Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage
H40.1423	Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage
H40.1424	Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1430	Capsular glaucoma with pseudoexfoliation of lens, bilateral, stage unspecified
H40.1431	Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
H40.1432	Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
H40.1433	Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
H40.1434	Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage
H40.20x0	Unspecified primary angle-closure glaucoma, stage unspecified
H40.20x1	Unspecified primary angle-closure glaucoma, mild stage
H40.20x2	Unspecified primary angle-closure glaucoma, moderate stage
H40.20x3	Unspecified primary angle-closure glaucoma, severe stage
H40.20x4	Unspecified primary angle-closure glaucoma, indeterminate stage
H40.211	Acute angle-closure glaucoma, right eye
H40.212	Acute angle-closure glaucoma, left eye
H40.213	Acute angle-closure glaucoma, bilateral
H40.2210	Chronic angle-closure glaucoma, right eye, stage unspecified
H40.2211	Chronic angle-closure glaucoma, right eye, mild stage
H40.2212	Chronic angle-closure glaucoma, right eye, moderate stage
H40.2213	Chronic angle-closure glaucoma, right eye, severe stage
H40.2214	Chronic angle-closure glaucoma, right eye, indeterminate stage
H40.2220	Chronic angle-closure glaucoma, left eye, stage unspecified
H40.2221	Chronic angle-closure glaucoma, left eye, mild stage
H40.2222	Chronic angle-closure glaucoma, left eye, moderate stage
H40.2223	Chronic angle-closure glaucoma, left eye, severe stage
H40.2224	Chronic angle-closure glaucoma, left eye, indeterminate stage
H40.2230	Chronic angle-closure glaucoma, bilateral, stage unspecified
H40.2231	Chronic angle-closure glaucoma, bilateral, mild stage
H40.2232	Chronic angle-closure glaucoma, bilateral, moderate stage
H40.2233	Chronic angle-closure glaucoma, bilateral, severe stage
H40.2234	Chronic angle-closure glaucoma, bilateral, indeterminate stage
H40.231	Intermittent angle-closure glaucoma, right eye
H40.232	Intermittent angle-closure glaucoma, left eye
H40.233	Intermittent angle-closure glaucoma, bilateral
H40.241	Residual stage of angle-closure glaucoma, right eye
H40.242	Residual stage of angle-closure glaucoma, left eye
H40.243	Residual stage of angle-closure glaucoma, bilateral
H40.31x0	Glaucoma secondary to eye trauma, right eye, stage unspecified
H40.31x1	Glaucoma secondary to eye trauma, right eye, mild stage
H40.31x2	Glaucoma secondary to eye trauma, right eye, moderate stage
H40.31x3	Glaucoma secondary to eye trauma, right eye, severe stage
H40.31x4	Glaucoma secondary to eye trauma, right eye, indeterminate stage
H40.32x0	Glaucoma secondary to eye trauma, left eye, stage unspecified
H40.32x1	Glaucoma secondary to eye trauma, left eye, mild stage
H40.32x2	Glaucoma secondary to eye trauma, left eye, moderate stage
H40.32x3	Glaucoma secondary to eye trauma, left eye, severe stage
H40.32x4	Glaucoma secondary to eye trauma, left eye, indeterminate stage
H40.33x0	Glaucoma secondary to eye trauma, bilateral, stage unspecified
H40.33x1	Glaucoma secondary to eye trauma, bilateral, mild stage
H40.33x2	Glaucoma secondary to eye trauma, bilateral, moderate stage
H40.33x3	Glaucoma secondary to eye trauma, bilateral, severe stage
H40.33x4	Glaucoma secondary to eye trauma, bilateral, indeterminate stage
H40.41x0	Glaucoma secondary to eye inflammation, right eye, stage unspecified
H40.41x1	Glaucoma secondary to eye inflammation, right eye, mild stage
H40.41x2	Glaucoma secondary to eye inflammation, right eye, moderate stage
H40.41x3	Glaucoma secondary to eye inflammation, right eye, severe stage
H40.41x4	Glaucoma secondary to eye inflammation, right eye, indeterminate stage
H40.42x0	Glaucoma secondary to eye inflammation, left eye, stage unspecified
H40.42x1	Glaucoma secondary to eye inflammation, left eye, mild stage
H40.42x2	Glaucoma secondary to eye inflammation, left eye, moderate stage
H40.42x3	Glaucoma secondary to eye inflammation, left eye, severe stage
H40.42x4	Glaucoma secondary to eye inflammation, left eye, indeterminate stage
H40.43x0	Glaucoma secondary to eye inflammation, bilateral, stage unspecified
H40.43x1	Glaucoma secondary to eye inflammation, bilateral, mild stage
H40.43x2	Glaucoma secondary to eye inflammation, bilateral, moderate stage
H40.43x3	Glaucoma secondary to eye inflammation, bilateral, severe stage
H40.43x4	Glaucoma secondary to eye inflammation, bilateral, indeterminate stage
H40.51x0	Glaucoma secondary to other eye disorders, right eye, stage unspecified
H40.51x1	Glaucoma secondary to other eye disorders, right eye, mild stage
H40.51x2	Glaucoma secondary to other eye disorders, right eye, moderate stage
H40.51x3	Glaucoma secondary to other eye disorders, right eye, severe stage
H40.51x4	Glaucoma secondary to other eye disorders, right eye, indeterminate stage
H40.52x0	Glaucoma secondary to other eye disorders, left eye, stage unspecified
H40.52x1	Glaucoma secondary to other eye disorders, left eye, mild stage
H40.52x2	Glaucoma secondary to other eye disorders, left eye, moderate stage
H40.52x3	Glaucoma secondary to other eye disorders, left eye, severe stage
H40.52x4	Glaucoma secondary to other eye disorders, left eye, indeterminate stage
H40.53x0	Glaucoma secondary to other eye disorders, bilateral, stage unspecified
H40.53x1	Glaucoma secondary to other eye disorders, bilateral, mild stage
H40.53x2	Glaucoma secondary to other eye disorders, bilateral, moderate stage
H40.53x3	Glaucoma secondary to other eye disorders, bilateral, severe stage
H40.53x4	Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.61x0	Glaucoma secondary to drugs, right eye, stage unspecified
H40.61x1	Glaucoma secondary to drugs, right eye, mild stage
H40.61x2	Glaucoma secondary to drugs, right eye, moderate stage
H40.61x3	Glaucoma secondary to drugs, right eye, severe stage
H40.61x4	Glaucoma secondary to drugs, right eye, indeterminate stage
H40.62x0	Glaucoma secondary to drugs, left eye, stage unspecified
H40.62x1	Glaucoma secondary to drugs, left eye, mild stage
H40.62x2	Glaucoma secondary to drugs, left eye, moderate stage
H40.62x3	Glaucoma secondary to drugs, left eye, severe stage
H40.62x4	Glaucoma secondary to drugs, left eye, indeterminate stage
H40.63x0	Glaucoma secondary to drugs, bilateral, stage unspecified
H40.63x1	Glaucoma secondary to drugs, bilateral, mild stage
H40.63x2	Glaucoma secondary to drugs, bilateral, moderate stage
H40.63x3	Glaucoma secondary to drugs, bilateral, severe stage
H40.63x4	Glaucoma secondary to drugs, bilateral, indeterminate stage
H40.811	Glaucoma with increased episcleral venous pressure, right eye
H40.812	Glaucoma with increased episcleral venous pressure, left eye
H40.813	Glaucoma with increased episcleral venous pressure, bilateral
H40.821	Hypersecretion glaucoma, right eye
H40.822	Hypersecretion glaucoma, left eye
H40.823	Hypersecretion glaucoma, bilateral
H40.831	Aqueous misdirection, right eye
H40.832	Aqueous misdirection, left eye
H40.833	Aqueous misdirection, bilateral
H40.89	Other specified glaucoma
H40.9	Unspecified glaucoma
H42	Glaucoma in diseases classified elsewhere
H44.511	Absolute glaucoma, right eye
H44.512	Absolute glaucoma, left eye
H44.513	Absolute glaucoma, bilateral
P15.3	Birth injury to eye
Q15.0	Congenital glaucoma
T85.318A	Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter
T85.318D	Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, subsequent encounter
T85.318S	Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, sequela
T85.328A	Displacement of other ocular prosthetic devices, implants and grafts, initial encounter
T85.328D	Displacement of other ocular prosthetic devices, implants and grafts, subsequent encounter
T85.328S	Displacement of other ocular prosthetic devices, implants and grafts, sequela
T85.398A	Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter
T85.398D	Other mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
T85.398S	Other mechanical complication of other ocular prosthetic devices, implants and grafts, sequela
T86.8401	Corneal transplant rejection, right eye
T86.8402	Corneal transplant rejection, left eye
T86.8403	Corneal transplant rejection, bilateral
T86.8411	Corneal transplant failure, right eye
T86.8412	Corneal transplant failure, left eye
T86.8413	Corneal transplant failure, bilateral
T86.8481	Other complications of corneal transplant, right eye
T86.8482	Other complications of corneal transplant, left eye
T86.8483	Other complications of corneal transplant, bilateral
T86.8491	Unspecified complication of corneal transplant, right eye
T86.8492	Unspecified complication of corneal transplant, left eye
T86.8493	Unspecified complication of corneal transplant, bilateral
Z94.7	Corneal transplant status

Version Effective Date:

09/19/2022

Version Issued Date:

09/19/2022

Version Reissued Date:

06/26/2024