Crystal's MCW Coder Hub🧬 ICD-10 CM H34.231 - Retinal Artery Branch Occlusion, Right Eye
📋 Code Identity
| Field | Detail |
|---|---|
| ICD-10-CM Code | H34.231 |
| Full Descriptor | Retinal Artery Branch Occlusion, Right Eye |
| Abbreviation | BRAO - Right Eye |
| Code Type | ICD-10-CM Diagnosis (Billable) |
| Effective Date | FY 2026 (October 1, 2025 - September 30, 2026) |
| Chapter | 7 - Diseases of the Eye and Adnexa (H00-H59) |
| Block | H30-H36 - Disorders of Choroid and Retina |
| Category | H34 - Retinal Vascular Occlusions |
| Subcategory | H34.23 - Retinal Artery Branch Occlusion |
| Laterality | 6th character = 1 (Right Eye) |
| Chronic Condition Indicator | Chronic |
⚠️ Laterality Reminder: Always assign the most specific laterality available. Use H34.231 only when the right eye is clearly documented. Do not default to H34.239 (unspecified) if laterality can be determined from the record. Query the provider when documentation is ambiguous.
🔬 Clinical Description
A branch retinal artery occlusion (BRAO) is the sudden, complete or near-complete blockage of one of the smaller arterial branches that arise from the central retinal artery (CRA) after it enters the eye. Unlike a central retinal artery occlusion (CRAO), which affects the entire retinal arterial supply, BRAO affects only the sector of the retina supplied by the occluded branch — resulting in a sectoral, wedge-shaped area of retinal ischemia corresponding to the visual field loss the patient experiences.
The overwhelming majority of BRAOs are embolic in origin. The three main embolus types are:
- Cholesterol emboli (Hollenhorst plaques) — bright, yellow-orange, refractile; most common; originate from ipsilateral carotid atherosclerosis
- Calcific emboli — white, non-refractile; originate from cardiac valves (aortic/mitral valve disease)
- Fibrin-platelet emboli — gray-white, dull; from thrombus in the heart or large vessels; often associated with atrial fibrillation
The blockage causes ischemia of the inner retinal layers (nerve fiber layer, ganglion cell layer, inner plexiform layer) in the affected sector. Acutely, the blocked area appears as grayish-white retinal opacification/pallor (ischemic edema from cytotoxic swelling of inner retinal neurons). Over days to weeks, this edema resolves, leaving variable degrees of permanent visual field loss depending on the severity and duration of ischemia. When the blocked area involves the papillomacular bundle, central vision (visual acuity) may be significantly affected.
Fluorescein angiography (FA) is the gold standard confirmatory study, showing delayed or absent arterial filling in the affected branch, retinal arteriovenous transit time prolongation, and leakage or staining along the affected vessel. OCT will show hyperreflectivity and thickening of the inner retinal layers acutely, progressing to inner retinal thinning (atrophy of the ganglion cell/inner plexiform layer complex) in the chronic phase. OCT angiography (OCTA) can non-invasively map the superficial and deep capillary plexus dropout corresponding to the ischemic zone.
🧠 BRAO as a Stroke Equivalent: The AAO 2025 clinical practice guidelines classify BRAO as a stroke equivalent requiring urgent systemic evaluation, including carotid Doppler, cardiac workup (echocardiogram, Holter monitor), and fasting lipid/glucose panels. In patients > 50, giant cell arteritis (GCA) must be ruled out. Younger patients (<50) should be worked up for hypercoagulable states and vasculitis.
👁️ Visual Prognosis: Visual prognosis for BRAO is generally better than for CRAO. Many patients retain good central visual acuity if the macula is not directly involved. However, permanent sectoral visual field defects are common, and neovascularization can develop in the ischemic zone, requiring close follow-up and potential laser treatment.
🌳 Code Tree
H34 - Retinal Vascular Occlusions
│
├── H34.0 - Transient Retinal Artery Occlusion
│ ├── H34.00 - Unspecified eye
│ ├── H34.01 - Right eye
│ ├── H34.02 - Left eye
│ └── H34.03 - Bilateral
│
├── H34.1 - Central Retinal Artery Occlusion
│ ├── H34.10 - Unspecified eye
│ ├── H34.11 - Right eye
│ ├── H34.12 - Left eye
│ └── H34.13 - Bilateral
│
├── H34.2 - Other Retinal Artery Occlusions
│ ├── H34.21 - Partial Retinal Artery Occlusion (Hollenhorst Plaque)
│ │ ├── H34.211 - Right eye
│ │ ├── H34.212 - Left eye
│ │ ├── H34.213 - Bilateral
│ │ └── H34.219 - Unspecified eye
│ │
│ └── H34.23 - Retinal Artery Branch Occlusion
│ ├── H34.231 - Right eye ◀ THIS CODE
│ ├── H34.232 - Left eye
│ ├── H34.233 - Bilateral
│ └── H34.239 - Unspecified eye
│
└── H34.8 - Other Retinal Vascular Occlusions
├── H34.81 - Central Retinal Vein Occlusion
│ ├── H34.8110 - Right eye, with macular edema
│ ├── H34.8111 - Right eye, with retinal neovascularization
│ ├── H34.8112 - Right eye, stable
│ └── (etc.)
├── H34.82 - Venous Engorgement
└── H34.83 - Tributary (Branch) Retinal Vein Occlusion
✅ Includes
The following clinical presentations are captured under the H34.23x subcategory:
- Branch retinal artery occlusion (BRAO) — occlusion of any secondary or tertiary branch of the central retinal artery distal to the optic disc
- Embolic BRAO — from cholesterol (Hollenhorst), calcific, or fibrin-platelet emboli
- Non-embolic BRAO — including vasospasm, vasculitis (e.g., GCA), coagulopathy-related thrombosis, or inflammatory conditions
- Acute ischemic edema of the inner retina in a sectoral distribution
- Sectoral or quadrantic visual field defects secondary to retinal ischemia from branch arterial occlusion
🚫 Excludes
Excludes 1 (Cannot be coded simultaneously — mutually exclusive)
| Excluded Code | Description | Rationale |
|---|---|---|
| G45.3 | Amaurosis fugax | Amaurosis fugax is a transient embolic event causing temporary monocular vision loss with no permanent retinal ischemia visible on exam; coded under cerebrovascular TIA, not structural retinal pathology. Do not code H34.231 with G45.3 for the same episode. |
📝 Coder Distinction: If the patient had prior amaurosis fugax and now presents with a new confirmed BRAO, you would code H34.231 for the current encounter and may reference the history separately. They represent different clinical events.
🏥 HCC (Hierarchical Condition Category)
| Field | Detail |
|---|---|
| HCC Mapped? | ❌ No — H34.231 does not map to a CMS-HCC v28 risk adjustment category |
| RAF Score Contribution | None directly from this code |
| Risk Adjustment Relevance | Low — retinal vascular occlusion codes under H34.2x do not carry HCC weight |
💡 RAF Strategy: While H34.231 itself has no HCC value, its underlying causes do. Capture all documented comorbidities:
🏨 MS-DRG (Medicare Severity DRG)
| Field | Detail |
|---|---|
| CC Status | ✅ Yes — H34.231 is designated as a CC (Complication or Comorbidity) |
| Primary MS-DRG (PDx) | MS-DRG 124 - Other Disorders of the Eye with MCC |
| Alternate (PDx) | MS-DRG 125 - Other Disorders of the Eye without MCC/CC |
| MDC | MDC 02 - Diseases and Disorders of the Eye |
| As Secondary Dx | Acts as a CC, potentially upgrading the DRG of the principal diagnosis |
🏥 Inpatient Profee Tip: When H34.231 is the principal diagnosis, the patient lands in MDC 02. The DRG will shift between 124 and 125 depending on the presence of MCCs (e.g., acute stroke I63.9, sepsis, respiratory failure). When coded as a secondary diagnosis on an admission for another condition (e.g., admitted for TIA workup), it functions as a CC and can upgrade the working DRG — significant for reimbursement. Always verify the CC/MCC designation in the current CMS MS-DRG v42 Definitions Manual.
💊 Associated CPT Codes (Commonly Reported With H34.231)
wRVU values reflect 2025 CMS Medicare Physician Fee Schedule. Values may vary by payer and setting.
| CPT Code | Description | wRVU (Non-Fac) | wRVU (Facility) | Assistant Payable? |
|---|---|---|---|---|
| 92235 | Fluorescein angiography with interpretation and report, unilateral or bilateral | 0.92 | 0.92 | No |
| 92134 | Scanning computerized ophthalmic diagnostic imaging, posterior segment (OCT), with interpretation and report | 0.00 | 0.00 | No |
| 92137 | OCT posterior segment with OCT angiography (OCTA), with interpretation and report (new 2025) | 0.79 | 0.79 | No |
| 92240 | Indocyanine-green (ICG) angiography with interpretation and report | 0.92 | 0.92 | No |
| 92242 | Combined fluorescein and ICG angiography with interpretation and report | 1.38 | 1.38 | No |
| 92250 | Fundus photography with interpretation and report | 0.00 | 0.00 | No |
| 92228 | Screening dark adaptation measurement, with interpretation and report (new 2026) | TBD | TBD | No |
| 67228 | Treatment of extensive or progressive retinopathy, one or more sessions; photocoagulation | 3.09 | 3.09 | Yes - No |
| 67220 | Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation | 4.33 | 4.33 | No |
| 99205 | Office/outpatient E/M, new patient, high complexity | 3.50 | 3.50 | No |
| 99215 | Office/outpatient E/M, established patient, high complexity | 2.85 | 2.85 | No |
| 99253 | Inpatient consult, moderate complexity | 3.86 | 3.86 | No |
| 99254 | Inpatient consult, moderate-high complexity | 5.30 | 5.30 | No |
⚠️ NCCI/Bundling Notes:
- 92137 (OCTA) cannot be billed on the same day as 92134 (OCT posterior segment without angiography)
- 92137 can be billed on the same day as 92235, 92240, or 92242
- 92250 (fundus photography) has a 0.00 work RVU — the value is in practice expense (PE RVU); documentation of medical necessity is essential
- 67228 (PRP) for neovascularization secondary to BRAO ischemia is appropriately reported with H34.231 as the supporting diagnosis; confirm medical necessity documentation
🔧 Applicable Modifiers
| Modifier | Description | Use Case with H34.231 |
|---|---|---|
| -RT | Right side | Append to laterality-specific CPT ophthalmic imaging codes for right eye procedures |
| -LT | Left side | Use for contralateral eye procedures at the same encounter |
| -25 | Significant, separately identifiable E/M on same day as procedure | When an E/M visit occurs same day as FA, OCT, or laser; must meet threshold |
| -59 | Distinct procedural service | To break NCCI bundles when documentation supports separate, distinct procedures |
| -26 | Professional component only | When physician provides interpretation only (e.g., reads FA taken by a technician at a separate facility) |
| -TC | Technical component only | When facility bills for the equipment/technical portion only |
| -50 | Bilateral procedure | For bilateral imaging at the same session (e.g., bilateral FA 92235) |
| -GX | Notice of liability issued | Medicare Advantage/Part C use; voluntary ABN |
| -GA | Waiver of liability on file | When an ABN has been obtained for a potentially non-covered service |
📝 Coding Examples
Example 1 — Outpatient Retina Clinic (New Patient, Acute Presentation)
A 65-year-old male, new patient, presents urgently to retina clinic with sudden onset of an inferior visual field defect in the right eye beginning 2 hours prior. He has a history of hypertension and hyperlipidemia. Dilated fundus exam reveals a bright, yellow-orange refractile lesion at a superior temporal arterial bifurcation with surrounding sector of retinal whitening in the right eye. Fluorescein angiography is performed and confirms delayed superior temporal branch arterial filling with hypofluorescence of the ischemic zone. OCT-A is performed and interpreted the same day, demonstrating superficial capillary plexus dropout in the affected zone. Patient is referred emergently for stroke workup.
Diagnosis Codes:
- H34.231 - Retinal artery branch occlusion, right eye (Principal)
- I10 - Essential hypertension
- E78.5 - Hyperlipidemia, unspecified
CPT Codes:
- 99205 - -25 - Office/outpatient E/M, new patient, high complexity
- 92235 - -RT - Fluorescein angiography, right eye
- 92137 - -RT - OCT with OCT-A, right eye (cannot bill 92134 on same day)
Example 2 — Emergency Department Profee (Ophthalmology Consult)
A 58-year-old female presents to the ED with acute painless loss of vision in the superior-nasal field of the right eye. Ophthalmology is consulted. Dilated exam confirms a branch retinal artery occlusion of the inferior temporal branch, right eye, with visible Hollenhorst plaque. Fundus photos are taken. No FA available in the ED. Patient admitted for expedited TIA/stroke workup. Echocardiogram reveals mild mitral valve disease. Carotid Doppler ordered.
Diagnosis Codes:
- H34.231 - Retinal artery branch occlusion, right eye
- I10 - Essential hypertension
- I34.0 - Nonrheumatic mitral valve insufficiency (if documented)
CPT Codes (Profee):
- 99254 - Inpatient consult, moderate-high complexity
- 92250 - -RT - Fundus photography with interpretation
Example 3 — Follow-Up Visit, Chronic Phase with Neovascularization
A 72-year-old established patient returns 8 weeks after a confirmed BRAO of the right eye. OCT confirms inner retinal thinning in the superior temporal sector. Fundus exam now reveals new retinal neovascularization (NV) along the superior arcade. PRP laser is recommended and performed in the office to address NV secondary to ischemia.
Diagnosis Codes:
- H34.231 - Retinal artery branch occlusion, right eye (ongoing condition driving NV)
- H35.029 - Neovascularization of retina, unspecified eye (if documented as complication; use right eye code if available)
CPT Codes:
- 99215 - 25 - Established patient E/M, high complexity
- 92134 - RT - OCT posterior segment with interpretation
- 67228 - RT - Photocoagulation treatment, extensive retinopathy
Example 4 — Inpatient Facility Coding (DRG Assignment)
Patient admitted with BRAO right eye as principal diagnosis. Documented comorbidities: hypertension I10 (not a CC), hyperlipidemia E78.5 (not a CC). No MCC present.
MS-DRG Assignment:
- PDx: H34.231 → MDC 02
- Secondary: I10, E78.5
- Result: MS-DRG 125 - Other Disorders of the Eye without MCC/CC
If patient also has documented atrial fibrillation I48.91 (CC):
- Result: MS-DRG 124 - Other Disorders of the Eye with MCC (atrial fibrillation elevates to MCC tier in some groupers — verify with current v42 logic)
🔗 Related Diagnoses to Consider Coding Together
| Code | Description | Relationship to BRAO |
|---|---|---|
| I10 | Essential hypertension | Extremely common comorbidity; document and code |
| E78.5 | Hyperlipidemia, unspecified | Atherosclerotic risk factor driving emboli |
| I48.91 | Unspecified atrial fibrillation | Cardioembolic source; HCC-relevant — always capture |
| I65.21 | Occlusion and stenosis of right carotid artery | Ipsilateral carotid as embolic source |
| E11.9 | Type 2 diabetes mellitus without complications | Vascular risk factor; HCC-relevant |
| H35.029 | Neovascularization of retina | Complication of chronic ischemia from BRAO |
| H40.841 | Neovascular secondary angle-closure glaucoma, right eye (new FY2026) | Late complication if neovascularization involves angle |
| M31.6 | Other giant cell arteritis | Rule-out in patients >50 with BRAO |
| G45.3 | Amaurosis fugax | Excludes 1 — do NOT code simultaneously with H34.231 |
| Z87.39 | Personal history of other specified conditions | For past ocular vascular events |
🩺 Diagnostic Workup — Coding Medical Necessity Support
Documenting the following in the record supports medical necessity for associated CPT procedures billed with H34.231:
| Study | Supporting CPT | What to Document |
|---|---|---|
| Fluorescein Angiography | 92235 | Indication: confirm ischemic zone, rule out alternate etiology, evaluate extent of capillary non-perfusion |
| OCT Posterior Segment | 92134 | Indication: measure retinal edema, inner retinal layer thickness, monitor for atrophy |
| OCT Angiography | 92137 | Indication: non-invasive mapping of capillary plexus dropout in ischemic sector (cannot bill same day as 92134) |
| Fundus Photography | 92250 | Indication: document optic disc, embolic plaque location, retinal pallor extent for comparison |
| PRP Laser | 67228 | Indication: retinal neovascularization secondary to ischemia — document NV presence and location |
📌 ICD-9-CM Crosswalk
| ICD-9-CM | Description |
|---|---|
| 362.32 | Arterial tributary or branch occlusion |
🧑💻 Coder Pearls
- Verify laterality every time. H34.231 = right eye only. If documentation is ambiguous, query before assigning H34.239.
- BRAO ≠ PRAO ≠ CRAO. Branch occlusion (H34.231) is a separate vessel event from partial (H34.211) or central (H34.11) occlusion. Each has its own code family.
- BRAO is a CC in the inpatient world. Even as a secondary diagnosis, H34.231 can influence DRG assignment — always code all documented comorbidities.
- Capture the HCC opportunities upstream. Atrial fibrillation, carotid stenosis, and diabetes are the real RAF score drivers here — they live in the comorbidity documentation.
- AAO 2025 Guidelines mandate stroke workup. If the record documents systemic workup (carotid Doppler, echo, Holter), code the findings — don’t leave cardiovascular comorbidities on the table.
- OCTA (2025+) is the hot new code. 92137 launched in 2025 and maps perfectly to BRAO staging. Monitor NCCI edits — cannot bundle with 92134 same day.
- New 2026 code 92228 (dark adaptation screening) is unlikely to be used with acute BRAO but may appear in chronic follow-up — know it exists.
- Neovascularization is a late complication. When NV develops weeks to months after BRAO, add a neovascularization code. If NV-glaucoma develops, consider new FY2026 code H40.841.
Sources: ICD-10-CM FY2026 Tabular List, CMS.gov; AAPC Codify H34.23x; CMS ICD-10-CM/PCS MS-DRG v42 Definitions Manual; CMS Billing & Coding: Scanning Computerized Ophthalmic Diagnostic Imaging A57600; AAO Clinical Practice Guidelines - Retinal and Ophthalmic Artery Occlusions, Feb 2025; Retina Today - OCT: What to Know for 2025; Retinal Physician - OCTA Documentation and NCCI Edits, Jan 2026; Review of Ophthalmology - Coding and Reimbursement 2026 Update; Ophthalmol Retina - BRAO Visual Outcomes Community Study, Feb 2026; CMS 2025 Medicare Physician Fee Schedule Final Rule