Ocular Photoscreening Form

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Ocular Photoscreening

Guideline Instrument-based ocular screening using photoscreening is covered as medically necessary for vision screening for the following:
 As a preventive screening instrument for children 1–3 years of age (ends on 4th birthday)
 Individuals 4 years of age and older who are developmentally delayed and are unable or unwilling to cooperate with routine visual acuity screening Limitations/Exclusions Instrument-based ocular screening using photoscreening is unproven and not medically necessary for all other patient populations including children younger than 1 year of age. More age-appropriate screening methods are available for these populations.
Retinal birefringence scanning for the detection of eye misalignment or strabismus (CPT 0469T) is not considered medically necessary, as its effectiveness has not been established. Clinical Evidence Ocular photoscreening has been investigated as an alternative screening method to detect risk factors for amblyopia, which include strabismus, high refractive errors, anisometropia, and media opacities. Many children permanently lose vision each year as a result of these treatable ocular disease processes. Early diagnosis and

Page 2 of 15 treatment of these conditions has been shown to yield better visual outcomes.
The U.S. Preventive Services Task Force (USPSTF, 2017) recommended vision screening for amblyopia and its risk factors in children aged 3 to 5 years. Evidence was insufficient to assess the benefits and harms of vision screening in children younger than 3 years. Various screening tests are used in primary care to identify visual impairment among children, including visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus). Photoscreeners (instruments that detect amblyogenic risk factors and refractive errors) may also be used.
Infants and young preverbal children are difficult to screen because they are unable to provide subjective responses to visual acuity testing and do not easily cooperate with testing of ocular alignment or stereoacuity (AAP, 2002). For similar reasons, it also is difficult to screen certain older children, such as those who are nonverbal or have developmental delays. Ocular photoscreening has been used to screen for amblyogenic factors, such as strabismus, media opacities, and significant refractive errors, in children (AAP, 2002). An advantage of ocular photoscreening over standard methods of testing visual acuity, ocular alignment and stereoacuity is that photoscreening requires little cooperation from the child, other than having to fixate on the appropriate target long enough for photoscreening. Thus, photoscreening has the potential to improve vision screening rates in preverbal children and those with developmental delays who are the most difficult to screen. Many of the children that are most difficult to screen using conventional methods are also at highest risk of amblyopia (e.g., premature infants, children with developmental delays). In a retrospective study, Longmuir et al. (2013) reported their experience with vision screening in children and compared the results of photoscreening in children younger than 3 years with those of children of preschool age and older. During the 11 years of the study, 210,695 photoscreens on children were performed at 13,750 sites. In the 3 years old. According to the authors, these results confirm that early screening, before amblyopia is more pronounced, can reliably detect amblyogenic risk factors in children younger than 3 years of age, and they recommend initiation of photoscreening in children aged 1 year and older.
In a cross-sectional study, Longmuir et al. (2010) reported on a cohort of preschool children screened by a photoscreening program (using MTI PhotoScreener) over a 9-year period from a single, statewide vision screening effort. Children who failed the photoscreening were referred to local eye care professionals who performed a comprehensive eye evaluation. Over the 9 years of the continuously operating program, 147,809 children underwent photoscreens to detect amblyopic risk factors at 9746 sites. Because of abnormal photoscreen results, 6247 children (4.2%) were referred. The overall positive predictive value (PPV) of the MTI PhotoScreener was 94.2%. Professional Societies American Academy of Ophthalmology (AAO)
The American Academy of Ophthalmology (AAO) Preferred Practice Patterns for Pediatric Eye Evaluations (2017) state that vision screening should be performed at an early age and at regular intervals throughout childhood. The elements of vision screening vary depending on the age and level of cooperation of the child. Subjective visual acuity testing is preferred to instrument-based screening in children who are able to participate reliably. Instrument-based screening is useful for some young children and those with developmental delays. Instrument- based screening techniques, such as photoscreening and autorefraction, are useful for assessing amblyopia and reduced-vision risk factors for children ages 1 to 5 years, as this is a critical time for visual development. Instrument- based screening can occur for children at age 6 years and older when children cannot participate in optotype-based screening. American Academy of Ophthalmology/American Association for Pediatric Ophthalmology and Strabismus / American Association of Certified Orthoptists

Page 3 of 15 The American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists coauthored a policy statement regarding the use of instrument-based screening devices. These devices are available commercially and have had extensive validation, both in field studies as well as in the pediatrician’s offices. Screening instruments detect amblyopia, high refractive error, and strabismus, which are the most common conditions producing visual impairment in children. If available, they can be used at any age but have better success after 18 months of age. Instrument-based screening can be repeated at each annual preventive medicine encounter through 5 years of age or until visual acuity can be assessed reliably using optotypes. Using these techniques in children younger than 6 years can enhance detection of conditions that may lead to amblyopia and/or strabismus compared with traditional methods of assessment (Donahue and Baker, 2016). Procedure Codes
99174 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with remote analysis and report 99177 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with on- site analysis

ICD-10 Diagnoses E78.71 Barth syndrome E78.72 Smith-Lemli-Opitz syndrome F07.9 Unspecified personality and behavioral disorder due to known physiological condition F09 Unspecified mental disorder due to known physiological condition F45.8 Other somatoform disorders F70 Mild intellectual disabilities F71 Moderate intellectual disabilities F72 Severe intellectual disabilities F73 Profound intellectual disabilities F78 Other intellectual disabilities F79 Unspecified intellectual disabilities F80.4 Speech and language development delay due to hearing loss F82 Specific developmental disorder of motor function F84.0 Autistic disorder F84.3 Other childhood disintegrative disorder F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type

Page 4 of 15 F90.2 Attention-deficit hyperactivity disorder, combined type F90.8 Attention-deficit hyperactivity disorder, other type F90.9 Attention-deficit hyperactivity disorder, unspecified type G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] G20 Parkinson's disease G21.4 Vascular parkinsonism G23.0 Hallervorden-Spatz disease G23.1 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski] G23.2 Striatonigral degeneration G23.8 Other specified degenerative diseases of basal ganglia G23.9 Degenerative disease of basal ganglia, unspecified G37.0 Diffuse sclerosis of central nervous system G37.5 Concentric sclerosis [Balo] of central nervous system G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus

Page 5 of 15 G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus G40.801 Other epilepsy, not intractable, with status epilepticus G40.802 Other epilepsy, not intractable, without status epilepticus G40.803 Other epilepsy, intractable, with status epilepticus G40.804 Other epilepsy, intractable, without status epilepticus G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus G40.821 Epileptic spasms, not intractable, with status epilepticus G40.822 Epileptic spasms, not intractable, without status epilepticus G40.823 Epileptic spasms, intractable, with status epilepticus G40.824 Epileptic spasms, intractable, without status epilepticus G40.833 Dravet syndrome, intractable with status epilepticus
G40.834 Dravet syndrome, intractable, without status epilepticus
G40.89 Other seizures G40.901 Epilepsy, unspecified, not intractable, with status epilepticus G40.909 Epilepsy, unspecified, not intractable, without status epilepticus G40.911 Epilepsy, unspecified, intractable, with status epilepticus G40.919 Epilepsy, unspecified, intractable, without status epilepticus G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus G40.A09 Absence epileptic syndrome, not intractable, without status epilepticus G40.A11 Absence epileptic syndrome, intractable, with status epilepticus G40.A19 Absence epileptic syndrome, intractable, without status epilepticus G46.3 Brain stem stroke syndrome G46.4 Cerebellar stroke syndrome

G46.5 Pure motor lacunar syndrome G46.6 Pure sensory lacunar syndrome G46.7 Other lacunar syndromes G46.8 Other vascular syndromes of brain in cerebrovascular diseases G52.7 Disorders of multiple cranial nerves

Page 6 of 15 G60.8 Other hereditary and idiopathic neuropathies G71.20 Congenital myopathy, unspecified
G71.21 Nemaline myopathy
G71.220 X-linked myotubular myopathy
G71.228 Other centronuclear myopathy
G71.29 Other congenital myopathy
G72.3 Periodic paralysis
G80.0 Spastic quadriplegic cerebral palsy G80.1 Spastic diplegic cerebral palsy G80.2 Spastic hemiplegic cerebral palsy G80.3 Athetoid cerebral palsy G80.4 Ataxic cerebral palsy G80.8 Other cerebral palsy G80.9 Cerebral palsy, unspecified G83.81 Brown-Sequard syndrome G83.82 Anterior cord syndrome G83.83 Posterior cord syndrome G83.84 Todd's paralysis (postepileptic) G83.89 Other specified paralytic syndromes G83.9 Paralytic syndrome, unspecified G90.09 Other idiopathic peripheral autonomic neuropathy G90.3 Multi-system degeneration of the autonomic nervous system G93.1 Anoxic brain damage, not elsewhere classified G97.31 Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure G97.32 Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating other procedure H93.25 Central auditory processing disorder I67.2 Cerebral atherosclerosis I67.81 Acute cerebrovascular insufficiency I67.82 Cerebral ischemia I67.89 Other cerebrovascular disease I68.0 Cerebral amyloid angiopathy I68.8 Other cerebrovascular disorders in diseases classified elsewhere I69.00 Unspecified sequelae of nontraumatic subarachnoid hemorrhage I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage

Page 7 of 15 I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I69.019 Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I69.020 Aphasia following nontraumatic subarachnoid hemorrhage I69.021 Dysphasia following nontraumatic subarachnoid hemorrhage I69.023 Fluency disorder following nontraumatic subarachnoid hemorrhage I69.031 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right dominant side I69.032 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left dominant side I69.033 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right non- dominant side I69.034 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non- dominant side I69.039 Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting unspecified side I69.041 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side I69.042 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side I69.043 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non- dominant side I69.044 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non- dominant side I69.049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting unspecified side I69.051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side I69.052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side I69.053 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non- dominant side I69.054 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non- dominant side I69.059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side I69.061 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right dominant side I69.062 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left dominant side I69.063 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right non- dominant side I69.064 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left non- dominant side I69.065 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage, bilateral I69.069 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting unspecified side I69.090 Apraxia following nontraumatic subarachnoid hemorrhage I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage I69.092 Facial weakness following nontraumatic subarachnoid hemorrhage I69.093 Ataxia following nontraumatic subarachnoid hemorrhage I69.098 Other sequelae following nontraumatic subarachnoid hemorrhage I69.10 Unspecified sequelae of nontraumatic intracerebral hemorrhage I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage

Page 8 of 15 I69.111 Memory deficit following nontraumatic intracerebral hemorrhage I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I69.119 Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I69.120 Aphasia following nontraumatic intracerebral hemorrhage I69.121 Dysphasia following nontraumatic intracerebral hemorrhage I69.123 Fluency disorder following nontraumatic intracerebral hemorrhage I69.131 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right dominant side I69.132 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left dominant side I69.133 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non- dominant side I69.134 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non- dominant side I69.139 Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting unspecified side I69.141 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side I69.142 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side I69.143 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non- dominant side I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side I69.149 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting unspecified side I69.151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side I69.152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side I69.153 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non- dominant side I69.154 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non- dominant side I69.159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified side I69.161 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right dominant side I69.162 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left dominant side I69.163 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right non- dominant side I69.164 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non- dominant side I69.165 Other paralytic syndrome following nontraumatic intracerebral hemorrhage, bilateral I69.169 Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting unspecified side I69.190 Apraxia following nontraumatic intracerebral hemorrhage I69.191 Dysphagia following nontraumatic intracerebral hemorrhage I69.192 Facial weakness following nontraumatic intracerebral hemorrhage I69.193 Ataxia following nontraumatic intracerebral hemorrhage I69.198 Other sequelae of nontraumatic intracerebral hemorrhage

Page 9 of 15 I69.20 Unspecified sequelae of other nontraumatic intracranial hemorrhage I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage I69.211 Memory deficit following other nontraumatic intracranial hemorrhage I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I69.219 Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I69.220 Aphasia following other nontraumatic intracranial hemorrhage I69.221 Dysphasia following other nontraumatic intracranial hemorrhage I69.223 Fluency disorder following other nontraumatic intracranial hemorrhage I69.231 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right dominant side I69.232 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left dominant side I69.233 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non- dominant side I69.234 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non- dominant side I69.239 Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting unspecified side I69.241 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side I69.242 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side I69.243 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non- dominant side I69.244 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non- dominant side I69.249 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting unspecified side I69.251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side I69.252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side I69.253 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non- dominant side I69.254 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non- dominant side I69.259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting unspecified side I69.261 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right dominant side I69.262 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left dominant side I69.263 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right non- dominant side I69.264 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left non- dominant side I69.265 Other paralytic syndrome following other nontraumatic intracranial hemorrhage, bilateral I69.269 Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting unspecified side I69.290 Apraxia following other nontraumatic intracranial hemorrhage I69.291 Dysphagia following other nontraumatic intracranial hemorrhage I69.292 Facial weakness following other nontraumatic intracranial hemorrhage

Page 10 of 15 I69.293 Ataxia following other nontraumatic intracranial hemorrhage I69.298 Other sequelae of other nontraumatic intracranial hemorrhage I69.30 Unspecified sequelae of cerebral infarction I69.310 Attention and concentration deficit following cerebral infarction I69.311 Memory deficit following cerebral infarction I69.312 Visuospatial deficit and spatial neglect following cerebral infarction I69.313 Psychomotor deficit following cerebral infarction I69.314 Frontal lobe and executive function deficit following cerebral infarction I69.315 Cognitive social or emotional deficit following cerebral infarction I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction I69.319 Unspecified symptoms and signs involving cognitive functions following cerebral infarction I69.320 Aphasia following cerebral infarction I69.321 Dysphasia following cerebral infarction I69.323 Fluency disorder following cerebral infarction I69.331 Monoplegia of upper limb following cerebral infarction affecting right dominant side I69.332 Monoplegia of upper limb following cerebral infarction affecting left dominant side I69.333 Monoplegia of upper limb following cerebral infarction affecting right non-dominant side I69.334 Monoplegia of upper limb following cerebral infarction affecting left non-dominant side I69.339 Monoplegia of upper limb following cerebral infarction affecting unspecified side I69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant side I69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant side I69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side I69.344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant side I69.349 Monoplegia of lower limb following cerebral infarction affecting unspecified side I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side I69.353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side I69.361 Other paralytic syndrome following cerebral infarction affecting right dominant side I69.362 Other paralytic syndrome following cerebral infarction affecting left dominant side I69.363 Other paralytic syndrome following cerebral infarction affecting right non-dominant side I69.364 Other paralytic syndrome following cerebral infarction affecting left non-dominant side I69.365 Other paralytic syndrome following cerebral infarction, bilateral I69.369 Other paralytic syndrome following cerebral infarction affecting unspecified side I69.390 Apraxia following cerebral infarction

Page 11 of 15 I69.391 Dysphagia following cerebral infarction I69.392 Facial weakness following cerebral infarction I69.393 Ataxia following cerebral infarction I69.398 Other sequelae of cerebral infarction I69.80 Unspecified sequelae of other cerebrovascular disease I69.810 Attention and concentration deficit following other cerebrovascular disease I69.811 Memory deficit following other cerebrovascular disease I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease I69.813 Psychomotor deficit following other cerebrovascular disease I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease I69.815 Cognitive social or emotional deficit following other cerebrovascular disease I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease I69.819 Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease I69.820 Aphasia following other cerebrovascular disease I69.821 Dysphasia following other cerebrovascular disease I69.823 Fluency disorder following other cerebrovascular disease I69.831 Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side I69.832 Monoplegia of upper limb following other cerebrovascular disease affecting left dominant side I69.833 Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side I69.834 Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side I69.839 Monoplegia of upper limb following other cerebrovascular disease affecting unspecified side I69.841 Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side I69.842 Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side I69.843 Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side I69.844 Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side I69.849 Monoplegia of lower limb following other cerebrovascular disease affecting unspecified side I69.851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side I69.852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side I69.853 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant side I69.854 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side I69.859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side I69.861 Other paralytic syndrome following other cerebrovascular disease affecting right dominant side I69.862 Other paralytic syndrome following other cerebrovascular disease affecting left dominant side I69.863 Other paralytic syndrome following other cerebrovascular disease affecting right non-dominant side I69.864 Other paralytic syndrome following other cerebrovascular disease affecting left non-dominant side I69.865 Other paralytic syndrome following other cerebrovascular disease, bilateral

Page 12 of 15 I69.869 Other paralytic syndrome following other cerebrovascular disease affecting unspecified side I69.890 Apraxia following other cerebrovascular disease I69.891 Dysphagia following other cerebrovascular disease I69.892 Facial weakness following other cerebrovascular disease I69.893 Ataxia following other cerebrovascular disease I69.898 Other sequelae of other cerebrovascular disease I69.90 Unspecified sequelae of unspecified cerebrovascular disease I69.910 Attention and concentration deficit following unspecified cerebrovascular disease I69.911 Memory deficit following unspecified cerebrovascular disease I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease I69.913 Psychomotor deficit following unspecified cerebrovascular disease I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease I69.919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease I69.920 Aphasia following unspecified cerebrovascular disease I69.921 Dysphasia following unspecified cerebrovascular disease I69.923 Fluency disorder following unspecified cerebrovascular disease I69.931 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant side I69.932 Monoplegia of upper limb following unspecified cerebrovascular disease affecting left dominant side I69.933 Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non-dominant side I69.934 Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side I69.939 Monoplegia of upper limb following unspecified cerebrovascular disease affecting unspecified side I69.941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side I69.942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side I69.943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side I69.944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side I69.953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non- dominant side I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side I69.961 Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side I69.962 Other paralytic syndrome following unspecified cerebrovascular disease affecting left dominant side I69.963 Other paralytic syndrome following unspecified cerebrovascular disease affecting right non-dominant side

Page 13 of 15 I69.964 Other paralytic syndrome following unspecified cerebrovascular disease affecting left non-dominant side I69.965 Other paralytic syndrome following unspecified cerebrovascular disease, bilateral I69.969 Other paralytic syndrome following unspecified cerebrovascular disease affecting unspecified side I69.990 Apraxia following unspecified cerebrovascular disease I69.991 Dysphagia following unspecified cerebrovascular disease I69.992 Facial weakness following unspecified cerebrovascular disease I69.993 Ataxia following unspecified cerebrovascular disease I97.810 Intraoperative cerebrovascular infarction during cardiac surgery I97.811 Intraoperative cerebrovascular infarction during other surgery I97.820 Postprocedural cerebrovascular infarction following cardiac surgery I97.821 Postprocedural cerebrovascular infarction following other surgery Q05.0 Cervical spina bifida with hydrocephalus Q05.1 Thoracic spina bifida with hydrocephalus Q05.2 Lumbar spina bifida with hydrocephalus Q05.3 Sacral spina bifida with hydrocephalus Q05.4 Unspecified spina bifida with hydrocephalus Q05.5 Cervical spina bifida without hydrocephalus Q05.6 Thoracic spina bifida without hydrocephalus Q05.7 Lumbar spina bifida without hydrocephalus Q05.8 Sacral spina bifida without hydrocephalus Q05.9 Spina bifida, unspecified Q07.00 Arnold-Chiari syndrome without spina bifida or hydrocephalus Q07.01 Arnold-Chiari syndrome with spina bifida Q07.02 Arnold-Chiari syndrome with hydrocephalus Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus Q14.2 Congenital malformation of optic disc Q87.81 Alport syndrome Q90.0 Trisomy 21, nonmosaicism (meiotic nondisjunction) Q90.1 Trisomy 21, mosaicism (mitotic nondisjunction) Q90.2 Trisomy 21, translocation Q90.9 Down syndrome, unspecified Q91.0 Trisomy 18, nonmosaicism (meiotic nondisjunction) Q91.1 Trisomy 18, mosaicism (mitotic nondisjunction) Q91.2 Trisomy 18, translocation Q91.3 Trisomy 18, unspecified Q91.4 Trisomy 13, nonmosaicism (meiotic nondisjunction)

Page 14 of 15 Q91.5 Trisomy 13, mosaicism (mitotic nondisjunction) Q91.6 Trisomy 13, translocation Q91.7 Trisomy 13, unspecified Q92.0 Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction) Q92.1 Whole chromosome trisomy, mosaicism (mitotic nondisjunction) Q92.2 Partial trisomy Q92.5 Duplications with other complex rearrangements Q92.7 Triploidy and polyploidy Q92.8 Other specified trisomies and partial trisomies of autosomes Q92.9 Trisomy and partial trisomy of autosomes, unspecified Q93.0 Whole chromosome monosomy, nonmosaicism (meiotic nondisjunction) Q93.1 Whole chromosome monosomy, mosaicism (mitotic nondisjunction) Q93.2 Chromosome replaced with ring, dicentric or isochromosome Q93.3 Deletion of short arm of chromosome 4 Q93.4 Deletion of short arm of chromosome 5 Q93.5 Other deletions of part of a chromosome Q93.7 Deletions with other complex rearrangements Q93.81 Velo-cardio-facial syndrome Q93.88 Other microdeletions Q93.89 Other deletions from the autosomes Q93.9 Deletion from autosomes, unspecified Q95.2 Balanced autosomal rearrangement in abnormal individual Q95.3 Balanced sex/autosomal rearrangement in abnormal individual Q95.5 Individual with autosomal fragile site Q95.8 Other balanced rearrangements and structural markers Q95.9 Balanced rearrangement and structural marker, unspecified Q96.0 Karyotype 45, X Q96.1 Karyotype 46, X iso (Xq) Q96.2 Karyotype 46, X with abnormal sex chromosome, except iso (Xq) Q96.3 Mosaicism, 45, X/46, XX or XY Q96.4 Mosaicism, 45, X/other cell line(s) with abnormal sex chromosome Q96.8 Other variants of Turner's syndrome Q96.9 Turner's syndrome, unspecified Q98.0 Klinefelter syndrome karyotype 47, XXY Q98.1 Klinefelter syndrome, male with more than two X chromosomes Q98.3 Other male with 46, XX karyotype

Page 15 of 15 Q98.4 Klinefelter syndrome, unspecified Q99.2 Fragile X chromosome R29.5 Transient paralysis R41.840 Attention and concentration deficit R62.0 Delayed milestone in childhood Z01.00 Encounter for examination of eyes and vision without abnormal findings Z01.01 Encounter for examination of eyes and vision with abnormal findings

Revision History

  DATE

REVISION May 8, 2020 Added clarification that retinal birefringence scanning (CPT code 0469T) is not considered medically necessary.

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