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2019
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CMS Transmittals



National Coverage Determination
Procedure Code: 67041
Vitrectomy
CMS Policy Number: 80.11
Back to NCD List



To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

ICD-10Descriptor
E08.3511 Diab with prolif diabetic rtnop with macular edema, r eye
E08.3512 Diab with prolif diabetic rtnop with macular edema, left eye
E08.3513 Diabetes with prolif diabetic rtnop with macular edema, bi
E08.3521 Diab with prolif diab rtnop with trctn dtch macula, r eye
E08.3522 Diab with prolif diab rtnop with trctn dtch macula, left eye
E08.3523 Diab with prolif diabetic rtnop with trctn dtch macula, bi
E08.3531 Diab with prolif diab rtnop with trctn dtch n-mcla, r eye
E08.3532 Diab with prolif diab rtnop with trctn dtch n-mcla, left eye
E08.3533 Diab with prolif diabetic rtnop with trctn dtch n-mcla, bi
E08.3541 Diabetes with prolif diabetic rtnop with comb detach, r eye
E08.3542 Diab with prolif diabetic rtnop with comb detach, left eye
E08.3543 Diabetes with prolif diabetic rtnop with combined detach, bi
E08.3591 Diab with prolif diabetic rtnop without macular edema, r eye
E08.3592 Diab with prolif diab rtnop without macular edema, left eye
E08.3593 Diab with prolif diabetic rtnop without macular edema, bi
E08.36 Diabetes due to underlying condition w diabetic cataract
E09.3511 Drug/chem diab with prolif diab rtnop with mclr edema, r eye
E09.3512 Drug/chem diab with prolif diab rtnop with mclr edema, l eye
E09.3513 Drug/chem diab with prolif diab rtnop with macular edema, bi
E09.3521 Drug/chem diab w prolif diab rtnop w trctn dtch macula,r eye
E09.3522 Drug/chem diab w prolif diab rtnop w trctn dtch macula,l eye
E09.3523 Drug/chem diab w prolif diab rtnop w trctn dtch macula, bi
E09.3531 Drug/chem diab w prolif diab rtnop w trctn dtch n-mcla,r eye
E09.3532 Drug/chem diab w prolif diab rtnop w trctn dtch n-mcla,l eye
E09.3533 Drug/chem diab w prolif diab rtnop w trctn dtch n-mcla, bi
E09.3541 Drug/chem diab w prolif diab rtnop with comb detach, r eye
E09.3542 Drug/chem diab w prolif diab rtnop with comb detach, l eye
E09.3543 Drug/chem diab with prolif diab rtnop with comb detach, bi
E09.3591 Drug/chem diab with prolif diab rtnop w/o mclr edema, r eye
E09.3592 Drug/chem diab with prolif diab rtnop w/o mclr edema, l eye
E09.3593 Drug/chem diab with prolif diab rtnop without mclr edema, bi
E09.36 Drug/chem diabetes mellitus w diabetic cataract
E10.3511 Type 1 diab with prolif diab rtnop with macular edema, r eye
E10.3512 Type 1 diab with prolif diab rtnop with macular edema, l eye
E10.3513 Type 1 diab with prolif diab rtnop with macular edema, bi
E10.3521 Type 1 diab w prolif diab rtnop w trctn dtch macula, r eye
E10.3522 Type 1 diab w prolif diab rtnop w trctn dtch macula, l eye
E10.3523 Type 1 diab w prolif diab rtnop with trctn dtch macula, bi
E10.3531 Type 1 diab w prolif diab rtnop w trctn dtch n-mcla, r eye
E10.3532 Type 1 diab w prolif diab rtnop w trctn dtch n-mcla, l eye
E10.3533 Type 1 diab w prolif diab rtnop with trctn dtch n-mcla, bi
E10.3541 Type 1 diab with prolif diab rtnop with comb detach, r eye
E10.3542 Type 1 diab with prolif diab rtnop with comb detach, l eye
E10.3543 Type 1 diab with prolif diabetic rtnop with comb detach, bi
E10.3591 Type 1 diab with prolif diab rtnop without mclr edema, r eye
E10.3592 Type 1 diab with prolif diab rtnop without mclr edema, l eye
E10.3593 Type 1 diab with prolif diab rtnop without macular edema, bi
E10.36 Type 1 diabetes mellitus with diabetic cataract
E11.3511 Type 2 diab with prolif diab rtnop with macular edema, r eye
E11.3512 Type 2 diab with prolif diab rtnop with macular edema, l eye
E11.3513 Type 2 diab with prolif diab rtnop with macular edema, bi
E11.3521 Type 2 diab w prolif diab rtnop w trctn dtch macula, r eye
E11.3522 Type 2 diab w prolif diab rtnop w trctn dtch macula, l eye
E11.3523 Type 2 diab w prolif diab rtnop with trctn dtch macula, bi
E11.3531 Type 2 diab w prolif diab rtnop w trctn dtch n-mcla, r eye
E11.3532 Type 2 diab w prolif diab rtnop w trctn dtch n-mcla, l eye
E11.3533 Type 2 diab w prolif diab rtnop with trctn dtch n-mcla, bi
E11.3541 Type 2 diab with prolif diab rtnop with comb detach, r eye
E11.3542 Type 2 diab with prolif diab rtnop with comb detach, l eye
E11.3543 Type 2 diab with prolif diabetic rtnop with comb detach, bi
E11.3591 Type 2 diab with prolif diab rtnop without mclr edema, r eye
E11.3592 Type 2 diab with prolif diab rtnop without mclr edema, l eye
E11.3593 Type 2 diab with prolif diab rtnop without macular edema, bi
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.39 Type 2 diabetes w oth diabetic ophthalmic complication
E13.3511 Oth diab with prolif diab rtnop with macular edema, r eye
E13.3512 Oth diab with prolif diab rtnop with macular edema, left eye
E13.3513 Oth diab with prolif diabetic rtnop with macular edema, bi
E13.3521 Oth diab w prolif diab rtnop with trctn dtch macula, r eye
E13.3522 Oth diab w prolif diab rtnop with trctn dtch macula, l eye
E13.3523 Oth diab with prolif diab rtnop with trctn dtch macula, bi
E13.3531 Oth diab w prolif diab rtnop with trctn dtch n-mcla, r eye
E13.3532 Oth diab w prolif diab rtnop with trctn dtch n-mcla, l eye
E13.3533 Oth diab with prolif diab rtnop with trctn dtch n-mcla, bi
E13.3541 Oth diab with prolif diabetic rtnop with comb detach, r eye
E13.3542 Oth diab with prolif diab rtnop with comb detach, left eye
E13.3543 Oth diabetes with prolif diabetic rtnop with comb detach, bi
E13.3591 Oth diab with prolif diab rtnop without macular edema, r eye
E13.3592 Oth diab with prolif diab rtnop without macular edema, l eye
E13.3593 Oth diab with prolif diab rtnop without macular edema, bi
E13.36 Other specified diabetes mellitus with diabetic cataract
H16.241 Ophthalmia nodosa, right eye
H16.242 Ophthalmia nodosa, left eye
H16.243 Ophthalmia nodosa, bilateral
H20.11 Chronic iridocyclitis, right eye
H20.12 Chronic iridocyclitis, left eye
H20.13 Chronic iridocyclitis, bilateral
H20.21 Lens-induced iridocyclitis, right eye
H20.22 Lens-induced iridocyclitis, left eye
H20.23 Lens-induced iridocyclitis, bilateral
H20.821 Vogt-Koyanagi syndrome, right eye
H20.822 Vogt-Koyanagi syndrome, left eye
H20.823 Vogt-Koyanagi syndrome, bilateral
H25.011 Cortical age-related cataract, right eye
H25.012 Cortical age-related cataract, left eye
H25.013 Cortical age-related cataract, bilateral
H25.031 Anterior subcapsular polar age-related cataract, right eye
H25.032 Anterior subcapsular polar age-related cataract, left eye
H25.033 Anterior subcapsular polar age-related cataract, bilateral
H25.041 Posterior subcapsular polar age-related cataract, right eye
H25.042 Posterior subcapsular polar age-related cataract, left eye
H25.043 Posterior subcapsular polar age-related cataract, bilateral
H25.21 Age-related cataract, morgagnian type, right eye
H25.22 Age-related cataract, morgagnian type, left eye
H25.23 Age-related cataract, morgagnian type, bilateral
H25.811 Combined forms of age-related cataract, right eye
H25.812 Combined forms of age-related cataract, left eye
H25.813 Combined forms of age-related cataract, bilateral
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 Unspecified infantile and juvenile cataract, right eye
H26.002 Unspecified infantile and juvenile cataract, left eye
H26.003 Unspecified infantile and juvenile cataract, bilateral
H26.031 Infantile and juvenile nuclear cataract, right eye
H26.032 Infantile and juvenile nuclear cataract, left eye
H26.033 Infantile and juvenile nuclear cataract, bilateral
H26.061 Combined forms of infantile and juvenile cataract, right eye
H26.062 Combined forms of infantile and juvenile cataract, left eye
H26.063 Combined forms of infantile and juvenile cataract, bilateral
H26.09 Other infantile and juvenile cataract
H26.101 Unspecified traumatic cataract, right eye
H26.102 Unspecified traumatic cataract, left eye
H26.103 Unspecified traumatic cataract, bilateral
H26.111 Localized traumatic opacities, right eye
H26.112 Localized traumatic opacities, left eye
H26.113 Localized traumatic opacities, bilateral
H26.121 Partially resolved traumatic cataract, right eye
H26.122 Partially resolved traumatic cataract, left eye
H26.123 Partially resolved traumatic cataract, bilateral
H26.131 Total traumatic cataract, right eye
H26.132 Total traumatic cataract, left eye
H26.133 Total traumatic cataract, bilateral
H26.221 Cataract secondary to ocular disorders, right eye
H26.222 Cataract secondary to ocular disorders, left eye
H26.223 Cataract secondary to ocular disorders, bilateral
H26.31 Drug-induced cataract, right eye
H26.32 Drug-induced cataract, left eye
H26.33 Drug-induced cataract, bilateral
H26.40 Unspecified secondary cataract
H26.411 Soemmering's ring, right eye
H26.412 Soemmering's ring, left eye
H26.413 Soemmering's ring, bilateral
H26.491 Other secondary cataract, right eye
H26.492 Other secondary cataract, left eye
H26.493 Other secondary cataract, bilateral
H26.8 Other specified cataract
H26.9 Unspecified cataract
H27.01 Aphakia, right eye
H27.02 Aphakia, left eye
H27.03 Aphakia, bilateral
H27.111 Subluxation of lens, right eye
H27.112 Subluxation of lens, left eye
H27.113 Subluxation of lens, bilateral
H27.131 Posterior dislocation of lens, right eye
H27.132 Posterior dislocation of lens, left eye
H27.133 Posterior dislocation of lens, bilateral
H28 Cataract in diseases classified elsewhere
H30.101 Unsp disseminated chorioretinal inflammation, right eye
H30.102 Unsp disseminated chorioretinal inflammation, left eye
H30.103 Unsp disseminated chorioretinal inflammation, bilateral
H30.131 Dissem chorioretin inflammation, generalized, right eye
H30.132 Disseminated chorioretin inflammation, generalized, left eye
H30.133 Dissem chorioretin inflammation, generalized, bilateral
H30.811 Harada's disease, right eye
H30.812 Harada's disease, left eye
H30.813 Harada's disease, bilateral
H30.891 Other chorioretinal inflammations, right eye
H30.892 Other chorioretinal inflammations, left eye
H30.893 Other chorioretinal inflammations, bilateral
H30.91 Unspecified chorioretinal inflammation, right eye
H30.92 Unspecified chorioretinal inflammation, left eye
H30.93 Unspecified chorioretinal inflammation, bilateral
H31.301 Unspecified choroidal hemorrhage, right eye
H31.302 Unspecified choroidal hemorrhage, left eye
H31.303 Unspecified choroidal hemorrhage, bilateral
H31.401 Unspecified choroidal detachment, right eye
H31.402 Unspecified choroidal detachment, left eye
H31.403 Unspecified choroidal detachment, bilateral
H31.411 Hemorrhagic choroidal detachment, right eye
H31.412 Hemorrhagic choroidal detachment, left eye
H31.413 Hemorrhagic choroidal detachment, bilateral
H33.001 Unspecified retinal detachment with retinal break, right eye
H33.002 Unspecified retinal detachment with retinal break, left eye
H33.003 Unspecified retinal detachment with retinal break, bilateral
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
H33.101 Unspecified retinoschisis, right eye
H33.102 Unspecified retinoschisis, left eye
H33.103 Unspecified retinoschisis, bilateral
H33.191 Other retinoschisis and retinal cysts, right eye
H33.192 Other retinoschisis and retinal cysts, left eye
H33.193 Other retinoschisis and retinal cysts, bilateral
H33.21 Serous retinal detachment, right eye
H33.22 Serous retinal detachment, left eye
H33.23 Serous retinal detachment, bilateral
H33.301 Unspecified retinal break, right eye
H33.302 Unspecified retinal break, left eye
H33.303 Unspecified retinal break, bilateral
H33.311 Horseshoe tear of retina without detachment, right eye
H33.312 Horseshoe tear of retina without detachment, left eye
H33.313 Horseshoe tear of retina without 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
H33.41 Traction detachment of retina, right eye
H33.42 Traction detachment of retina, left eye
H33.43 Traction detachment of retina, bilateral
H33.8 Other retinal detachments
H34.8110 Central retinal vein occls, right eye, with macular edema
H34.8111 Central retinal vein occlusion, right eye, w rtnl neovas
H34.8120 Central retinal vein occlusion, left eye, with macular edema
H34.8121 Central retinal vein occlusion, left eye, w rtnl neovas
H34.8130 Central retinal vein occlusion, bi, with macular edema
H34.8131 Central retinal vein occlusion, bilateral, w rtnl neovas
H35.021 Exudative retinopathy, right eye
H35.022 Exudative retinopathy, left eye
H35.023 Exudative retinopathy, bilateral
H35.051 Retinal neovascularization, unspecified, right eye
H35.052 Retinal neovascularization, unspecified, left eye
H35.053 Retinal neovascularization, unspecified, bilateral
H35.061 Retinal vasculitis, right eye
H35.062 Retinal vasculitis, left eye
H35.063 Retinal vasculitis, bilateral
H35.071 Retinal telangiectasis, right eye
H35.072 Retinal telangiectasis, left eye
H35.073 Retinal telangiectasis, bilateral
H35.101 Retinopathy of prematurity, unspecified, right eye
H35.102 Retinopathy of prematurity, unspecified, left eye
H35.103 Retinopathy of prematurity, unspecified, bilateral
H35.161 Retinopathy of prematurity, stage 5, right eye
H35.162 Retinopathy of prematurity, stage 5, left eye
H35.163 Retinopathy of prematurity, stage 5, bilateral
H35.21 Other non-diabetic proliferative retinopathy, right eye
H35.22 Other non-diabetic proliferative retinopathy, left eye
H35.23 Other non-diabetic proliferative retinopathy, bilateral
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
H35.50 Unspecified hereditary retinal dystrophy
H35.51 Vitreoretinal dystrophy
H35.53 Other dystrophies primarily involving the sensory retina
H35.61 Retinal hemorrhage, right eye
H35.62 Retinal hemorrhage, left eye
H35.63 Retinal hemorrhage, bilateral
H35.81 Retinal edema
H40.831 Aqueous misdirection, right eye
H40.832 Aqueous misdirection, left eye
H40.833 Aqueous misdirection, bilateral
H40.89 Other specified glaucoma
H43.01 Vitreous prolapse, right eye
H43.02 Vitreous prolapse, left eye
H43.03 Vitreous prolapse, bilateral
H43.311 Vitreous membranes and strands, right eye
H43.312 Vitreous membranes and strands, left eye
H43.313 Vitreous membranes and strands, bilateral
H43.811 Vitreous degeneration, right eye
H43.812 Vitreous degeneration, left eye
H43.813 Vitreous degeneration, bilateral
H43.821 Vitreomacular adhesion, right eye
H43.822 Vitreomacular adhesion, left eye
H43.823 Vitreomacular adhesion, bilateral
H43.89 Other disorders of vitreous body
H43.9 Unspecified disorder of vitreous body
H44.001 Unspecified purulent endophthalmitis, right eye
H44.002 Unspecified purulent endophthalmitis, left eye
H44.003 Unspecified purulent endophthalmitis, bilateral
H44.021 Vitreous abscess (chronic), right eye
H44.022 Vitreous abscess (chronic), left eye
H44.023 Vitreous abscess (chronic), bilateral
H44.131 Sympathetic uveitis, right eye
H44.132 Sympathetic uveitis, left eye
H44.133 Sympathetic uveitis, bilateral
H44.19 Other endophthalmitis
H44.601 Unsp retained (old) intraocular fb, magnetic, right eye
H44.602 Unsp retained (old) intraocular fb, magnetic, left eye
H44.603 Unsp retained (old) intraocular fb, magnetic, bilateral
H44.641 Retained (old) magnetic fb in post wall of globe, right eye
H44.642 Retained (old) magnetic fb in post wall of globe, left eye
H44.643 Retained (old) magnetic fb in posterior wall of globe, bi
H44.651 Retained (old) magnetic fb in vitreous body, right eye
H44.652 Retained (old) magnetic fb in vitreous body, left eye
H44.653 Retained (old) magnetic fb in vitreous body, bilateral
H44.691 Retain (old) intraoc fb, magnet, in oth or mult sites, r eye
H44.692 Retain (old) intraoc fb, magnet, in oth or mult sites, l eye
H44.693 Retained (old) intraoc fb, magnet, in oth or mult sites, bi
H44.701 Unsp retained (old) intraocular fb, nonmagnetic, right eye
H44.702 Unsp retained (old) intraocular fb, nonmagnetic, left eye
H44.703 Unsp retained (old) intraocular fb, nonmagnetic, bilateral
H44.741 Retained (old) fb in posterior wall of globe, right eye
H44.742 Retained (old) fb in posterior wall of globe, left eye
H44.743 Retained (old) fb in posterior wall of globe, bilateral
H44.751 Retained (old) foreign body in vitreous body, right eye
H44.752 Retained (old) foreign body in vitreous body, left eye
H44.753 Retained (old) foreign body in vitreous body, bilateral
H44.791 Retain (old) intraoc fb, nonmag, in oth or mult sites, r eye
H44.792 Retain (old) intraoc fb, nonmag, in oth or mult sites, l eye
H44.793 Retained (old) intraoc fb, nonmag, in oth or mult sites, bi
H59.011 Keratopathy (bullous aphakic) fol cataract surgery, r eye
H59.012 Keratopathy (bullous aphakic) fol cataract surgery, left eye
H59.013 Keratopathy (bullous aphakic) following cataract surgery, bi
H59.021 Cataract (lens) fragmt in eye fol cataract surgery, r eye
H59.022 Cataract (lens) fragmt in eye fol cataract surgery, left eye
H59.023 Cataract (lens) fragments in eye fol cataract surgery, bi
H59.031 Cystoid macular edema following cataract surgery, right eye
H59.032 Cystoid macular edema following cataract surgery, left eye
H59.033 Cystoid macular edema following cataract surgery, bilateral
H59.091 Other disorders of the right eye following cataract surgery
H59.092 Other disorders of the left eye following cataract surgery
H59.093 Oth disorders of the eye following cataract surgery, bi
H59.811 Chorioretinal scars after surgery for detachment, right eye
H59.812 Chorioretinal scars after surgery for detachment, left eye
H59.813 Chorioretinal scars after surgery for detachment, bilateral
H59.88 Oth intraoperative complications of eye and adnexa, NEC
H59.89 Oth postproc comp and disorders of eye and adnexa, NEC
Q12.0 Congenital cataract
Q12.1 Congenital displaced lens
Q12.2 Coloboma of lens
Q12.3 Congenital aphakia
Q12.4 Spherophakia
Q12.8 Other congenital lens malformations
Q12.9 Congenital lens malformation, unspecified
Q14.0 Congenital malformation of vitreous humor
Q14.1 Congenital malformation of retina
S05.21XA Oclr lac/rupt w prolaps/loss of intraoc tissue, r eye, init
S05.22XA Oclr lac/rupt w prolaps/loss of intraoc tissue, l eye, init
S05.31XA Ocular lac w/o prolaps/loss of intraoc tissue, r eye, init
S05.32XA Ocular lac w/o prolaps/loss of intraoc tissue, l eye, init
S05.51XA Penetrating wound w foreign body of right eyeball, init
S05.52XA Penetrating wound w foreign body of left eyeball, init
S05.61XA Penetrating wound w/o foreign body of right eyeball, init
S05.62XA Penetrating wound w/o foreign body of left eyeball, init
S05.8X1A Other injuries of right eye and orbit, initial encounter
S05.8X2A Other injuries of left eye and orbit, initial encounter
S05.91XA Unspecified injury of right eye and orbit, initial encounter
S05.92XA Unspecified injury of left eye and orbit, initial encounter
T85.21XA Breakdown (mechanical) of intraocular lens, init encntr
T85.22XA Displacement of intraocular lens, initial encounter
T85.29XA Mech compl of intraocular lens, initial encounter
Z98.41 Cataract extraction status, right eye
Z98.42 Cataract extraction status, left eye
Z98.83 Filtering (vitreous) bleb after glaucoma surgery status

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