Crystal's MCW Coder Hub🧬 ICD-10 CM H35.3113 — Nonexudative AMD, Right Eye, Advanced Atrophic Without Subfoveal Involvement
Billable Code Confirmed
ICD-10 CM H35.3113 is a valid, billable 7-character ICD-10-CM code for FY2025. All seven characters are present:
H35(category) +.3(degeneration of macula) +1(nonexudative) +1(right eye) +3(advanced atrophic, no subfoveal involvement). No additional characters required.
Non-Billable Parent Codes — Never Submit These
- ❌
H35.311— 6-character header — missing staging character- ❌
H35.31— 5-character header — missing laterality AND staging Always submit H35.3113 (all 7 characters).
GA Is Consistently Undercoded Nationally — This Code Matters
A documented national study found that geographic atrophy is significantly underreported in ICD-10-CM coding, often incorrectly coded as intermediate dry AMD (H35.3112) when GA is actually present. GA is a distinct, advanced disease state with its own FDA-approved treatments — accurate assignment of H35.3113 or H35.3114 is not just a coding accuracy issue, it is a patient care documentation imperative that supports appropriate treatment authorization (Syfovre, Izervay), monitoring intensity, and vision impairment documentation.
🔍 Code Description
ICD-10 CM H35.3113 classifies nonexudative (dry) age-related macular degeneration of the right eye at the advanced atrophic stage, with geographic atrophy (GA) that does NOT involve the subfoveal center — meaning the atrophic lesion has reached the advanced stage of retinal pigment epithelium and photoreceptor loss but the foveal center (the point of maximum visual acuity) remains spared.1,2
This distinction from H35.3114 is clinically crucial: when GA spares the subfoveal center, the patient may retain surprisingly good central visual acuity despite having advanced AMD. However, paracentral scotomas (blind spots just off center), reading difficulty, and significant peripheral visual field loss within the macula are common. Critically, this is a disease-in-motion — GA enlarges at an average rate of approximately 1.5-2.5 mm² per year, and once the expanding atrophic lesion reaches the foveal center, vision drops precipitously. The window during which GA is present but subfoveal-sparing represents the highest-priority treatment opportunity for Syfovre and Izervay.
🌳 Code Tree / Hierarchy
H35.3 Degeneration of Macula and Posterior Pole
│
├── H35.31 Nonexudative AMD ❌ Non-billable header
│ │
│ └── H35.311 Right Eye ❌ Non-billable header
│ │
│ ├── H35.3110 Stage unspecified ⚠️ last resort
│ ├── H35.3111 Early dry stage
│ ├── H35.3112 Intermediate dry stage
│ ├── H35.3113 ADVANCED ATROPHIC — NO SUBFOVEAL GA ◀ THIS CODE ✅
│ └── H35.3114 Advanced atrophic — WITH subfoveal GA
The Subfoveal Distinction — The Single Most Important Coding Decision in Advanced Dry AMD
The 7th character difference between H35.3113 and H35.3114 represents a massive clinical and functional difference:
3→ GA present, fovea SPARED → VA may still be 20/25-20/60 → Central vision largely intact4→ GA involving foveal CENTER → VA typically 20/200+ → Legal blindness commonThe physician or retinal imaging report must document the relationship of GA to the foveal center. Look for language like: “geographic atrophy extending toward but not yet involving the foveal center,” “extrafoveal GA,” “subfoveal-sparing GA,” or “pericentral GA with foveal preservation.” These map to H35.3113. “GA involving the foveal center,” “subfoveal GA,” “central scotoma,” or “GA centered at the macula” maps to H35.3114. Query when the record does not specify.
📊 Clinical Staging at the Advanced Atrophic Stage
Beckman Classification — Full Table2
| Stage | ICD-10-CM (Right Eye) | GA Present? | Subfoveal? | FDA-Approved GA Rx? | AREDS2? | Typical VA |
|---|---|---|---|---|---|---|
| Early | H35.3111 | ❌ | N/A | ❌ | ❌ | 20/20-20/40 |
| Intermediate | H35.3112 | ❌ | N/A | ❌ | ✅ | 20/25-20/80 |
| Advanced, no subfoveal | H35.3113 | ✅ | ❌ Fovea SPARED | ✅ Syfovre/Izervay | ✅ Continue | 20/25-20/80+ (variable) |
| Advanced, subfoveal | H35.3114 | ✅ | ✅ Fovea INVOLVED | ✅ Syfovre/Izervay | ✅ Continue | 20/200+ |
Geographic Atrophy — The Defining Lesion of Advanced Dry AMD2,3
Geographic atrophy is defined as a sharply demarcated area of RPE loss with underlying choriocapillaris atrophy and overlying photoreceptor degeneration, visible on fundoscopy as a pale, well-circumscribed lesion with visible choroidal vessels. Key objective characteristics:
| GA Characteristic | Clinical Significance | Imaging Tool |
|---|---|---|
| Lesion area (mm²) | GA progression rate measured in mm²/year (~1.5-2.5 avg) | Fundus autofluorescence (FAF), OCT |
| Distance from foveal center | Determines H35.3113 vs H35.3114 | FAF, OCT with foveal overlay |
| Lesion pattern (focal/multifocal/confluent) | Multifocal GA progresses faster | FAF |
| Hyper-autofluorescent junctional zone | Active GA boundary — predicts progression direction | FAF |
| Subfoveal status | The H35.3113/H35.3114 distinction | OCT central foveal mapping |
Fundus Autofluorescence (FAF) Is the Gold Standard for GA Delineation
92250 with FAF filter provides the most accurate delineation of GA lesion size and boundaries, including the relationship to the foveal center. Standard fundus photography may not clearly differentiate GA from surrounding drusen burden. When coding H35.3113 vs H35.3114, the FAF or OCT report is the most reliable source for subfoveal involvement documentation. If only funduscopic exam findings are documented without imaging, a CDI query is appropriate to specify subfoveal status.
✅ Includes
The following clinical terms map to H35.3113 — right eye, advanced atrophic, no subfoveal involvement:1
- Nonexudative AMD, right eye, advanced atrophic — geographic atrophy NOT at subfoveal center
- Geographic atrophy (GA), right eye — extrafoveal / parafoveal / pericentral — fovea spared
- Advanced dry AMD, right eye — GA present, central fovea intact
- Subfoveal-sparing geographic atrophy, right eye
- Advanced age-related maculopathy, right eye — atrophic, central vision preserved
Pericentral GA Pattern — Particularly Clinically Significant at H35.3113
Pericentral GA is a recognized GA pattern in which the atrophic lesion forms a ring-like distribution around (but not yet including) the foveal center. This pattern is particularly associated with the complement pathway genetic variants (CFH, C3) and is more common in patients with concurrent pseudodrusen. Pericentral GA may cause significant functional impairment (reading difficulty, contrast loss) while technically still qualifying as H35.3113 (fovea spared). When pericentral GA is documented, the foveal center proximity makes this a high-urgency population for GA treatment initiation — the lesion is approaching the anatomic center from the periphery.
❌ Excludes
Excludes 2 — Separate Coding When Both Conditions Present1
| Code Range | Description | Action |
|---|---|---|
| E08.311-E08.359 | Drug/chemical-induced DM with diabetic retinopathy | Diabetic retinopathy code takes precedence when DM is the etiology |
| E10.311-E10.359 | Type 1 DM with diabetic retinopathy | Same |
| E11.311-E11.359 | Type 2 DM with diabetic retinopathy | Same |
| E13.311-E13.359 | Other specified DM with diabetic retinopathy | Same |
💊 FDA-Approved Geographic Atrophy Treatments
Geographic Atrophy — The First FDA-Approved Treatments in History
For decades, geographic atrophy had no approved disease-modifying treatments. That changed in 2023 with two complement pathway inhibitors that slow GA progression. Both target the complement cascade — the inflammatory pathway now understood as central to AMD pathogenesis.
Both GA Drugs Are Indicated for H35.3113 and H35.3114
Syfovre (Pegcetacoplan) — Complement C3 Inhibitor
| Field | Detail |
|---|---|
| Generic Name | Pegcetacoplan |
| Mechanism | Complement C3 inhibitor — blocks both the alternative and classical complement pathways upstream |
| FDA Approval | February 17, 2023 |
| HCPCS Code | J2781 — permanent (effective October 1, 2023) |
| Units per Injection | 15 units per injection (15mg/0.1mL dose) |
| Dosing Schedule | Every month OR every other month (every 60 days) |
| Administration | Intravitreal injection — 67028-RT (right eye) |
| Clinical Evidence | OAKS and DERBY trials: 17-22% slowing of GA progression vs sham at 24 months |
| NC Medicaid Note | Previously billed J3490; now J2781 — do not use J3490 for current claims [web:119] |
Syfovre J-Code Transition — J3490 Is Retired for This Drug
Syfovre was initially billed under J3490 (unclassified drugs) from approval in February 2023 until the permanent code assignment on October 1, 2023. After that date, J2781 is the required code. Claims submitted with J3490 for Syfovre dates of service after October 1, 2023 may be denied or require rework. Always confirm J2781 is being used for all current Syfovre billing.
Izervay (Avacincaptad Pegol) — Complement C5 Inhibitor
| Field | Detail |
|---|---|
| Generic Name | Avacincaptad pegol |
| Mechanism | Complement C5 inhibitor — blocks the terminal complement pathway downstream |
| FDA Approval | August 4, 2023 |
| HCPCS Code | J2782 — permanent (effective April 1, 2024) |
| Units per Injection | 20 units per 2mg dose |
| Dosing Schedule | Monthly (every 28-35 days) |
| Administration | Intravitreal injection — 67028-RT (right eye) |
| Clinical Evidence | GATHER1 and GATHER2 trials: statistically significant GA progression reduction at 12 months primary endpoint (only FDA-approved GA drug with 12-month primary endpoint significance) [web:120] |
C3 vs C5 Inhibition — Clinical Selection Context
Syfovre (C3) and Izervay (C5) act at different points in the complement cascade. C3 inhibition with Syfovre blocks more broadly upstream; C5 inhibition with Izervay is more targeted downstream. No head-to-head trial has compared them directly. The choice between drugs involves patient preference for dosing schedule (monthly vs every-other-month), payer coverage, and physician experience. From a coding standpoint, both link to H35.3113 and H35.3114 identically — the difference is only in the J-code and units billed.
💰 HCC Risk Adjustment (CMS-HCC v28)
| Field | Detail |
|---|---|
| CMS-HCC Model Version | v28 (2024-2025 Implementation) |
| HCC Assignment | ❌ Not Mapped |
| HCC Category | N/A |
| RAF Coefficient | 0.000 |
H35.3113 carries no direct HCC weight.
Vision Impairment Code — The CC Opportunity at H35.3113
At the advanced atrophic stage WITHOUT subfoveal involvement, VA varies widely — from surprisingly preserved (20/25) when GA is far from the fovea, to significant impairment (20/80-20/200) when GA is extensive or pericentral. When VA meets the low vision or blindness threshold, the H54.xx vision impairment code is separately codeable:
VA Range Code Description CC/MCC Status 20/70-20/160 OU H54.2x1 Low vision, right eye, category 1 Review payer CC list 20/200 or worse H54.11x Blindness, right eye Potential CC Legal blindness (best eye <20/200) H54.3 Unqualified visual loss Potential CC Document and code vision impairment when VA findings meet criteria — this both accurately captures the clinical burden and may drive the DRG tier from 126 to 125 in an inpatient encounter.
🏥 MS-DRG Assignment
MDC 02 — Diseases and Disorders of the Eye
| DRG | Title | Est. Relative Weight* |
|---|---|---|
| DRG 124 | Other Disorders of the Eye with MCC | ~0.95-1.15 |
| DRG 125 | Other Disorders of the Eye with CC | ~0.70-0.90 |
| DRG 126 | Other Disorders of the Eye without CC/MCC | ~0.50-0.70 |
*Verify against IPPS FY2025 Final Rule tables.
🔗 Related ICD-10-CM Codes
Stage Navigation — Where H35.3113 Sits
| Code | Description | Key Distinction | GA Rx? |
|---|---|---|---|
| H35.3112 | Intermediate dry, right eye | No GA yet — drusen/pigment only | ❌ |
| H35.3113 | Advanced, no subfoveal ← This Code | GA present, fovea SPARED | ✅ J2781/J2782 |
| H35.3114 | Advanced, subfoveal | GA at foveal CENTER | ✅ J2781/J2782 |
| H35.3211 | Exudative AMD, right eye, active CNV | Wet AMD conversion — different pathway | Anti-VEGF |
Bilateral Equivalent
| Code | Use When |
|---|---|
| H35.3133 | Both eyes advanced atrophic WITHOUT subfoveal — bilateral code preferred |
| H35.3113 + H35.3123 | Asymmetric bilateral — right no-subfoveal + left no-subfoveal but documented separately |
| H35.3113 + H35.3124 | Right eye no-subfoveal + left eye HAS subfoveal — different stages, separate codes required |
Commonly Co-Coded
| Code | Description | Why |
|---|---|---|
| H54.11x | Blindness/low vision, right eye | If VA ≤20/200 — separately codeable |
| H53.131 | Sudden visual loss, right eye | If acute change — CNV conversion? |
| H35.3211 | Exudative AMD, right eye | Co-occurring wet conversion — stop H35.3113 for right eye if CNV documented |
| Z82.1 | Family history of blindness/visual loss | Document risk factor |
| F17.210 | Nicotine dependence — cigarettes | Smoking — document; beta-carotene avoidance essential |
🛠️ CPT / HCPCS Codes — H35.3113 Encounters
GA Treatment Injection Visit
| Code | Description | Application |
|---|---|---|
| 67028-RT | Intravitreal injection of pharmacological agent, right eye | Required CPT for Syfovre or Izervay injection — link to H35.3113 |
| J2781 | Pegcetacoplan (Syfovre) injection | 15 units per 15mg injection — permanent J-code |
| J2782 | Avacincaptad pegol (Izervay) injection | 20 units per 2mg injection — permanent J-code |
| 92134 | OCT posterior segment | GA lesion size and progression monitoring — every visit |
| 92250 | Fundus photography/FAF | GA boundary delineation — FAF filter critical for GA measurement |
| 92014 | Comprehensive ophthalmological exam, established | Monitoring visit without injection |
Billing GA Drugs Without 67028 — A Common Error
The GA drug J-codes (J2781, J2782) represent the drug only — the intravitreal injection procedure must always be separately billed with 67028-RT. A claim with J2781 or J2782 but no 67028 is incomplete and will typically deny. Conversely, a claim with 67028-RT linked to H35.3113 but without a GA drug J-code (or an anti-VEGF J-code for a different diagnosis) requires documentation review to ensure the correct drug and diagnosis are linked.
GA Drug J-Code Units — Critical Billing Detail
- Syfovre J2781: Bill 15 units per injection (each unit = 1mg; 15mg dose = 15 units)
- Izervay J2782: Bill 20 units per 2mg dose (each unit = 0.1mg; 2mg = 20 units)
Unit billing errors are one of the most common GA drug claim issues. Verify units against the administered dose documentation in every claim.
Monitoring Protocol for H35.3113
GA Treatment Patients — Monthly Visits
Patients receiving Syfovre or Izervay injections require monthly (Izervay) or every-other-month (Syfovre EOM schedule) injections, driving a significantly higher visit frequency than monitoring-only AMD patients. Each injection visit includes 67028-RT + the drug J-code + 92134 (OCT for GA measurement and safety check). Monitoring-only H35.3113 patients (not yet on GA treatment or declining treatment) are seen every 3-6 months.
| Visit Type | CPT/HCPCS | Frequency |
|---|---|---|
| GA injection visit (Syfovre monthly) | 67028-RT + J2781 + 92134 | Monthly |
| GA injection visit (Syfovre every other month) | 67028-RT + J2781 + 92134 | Every 2 months |
| GA injection visit (Izervay) | 67028-RT + J2782 + 92134 | Monthly |
| GA monitoring only (no injection) | 92014 + 92134 + 92250/FAF | Every 3-6 months |
| Annual comprehensive exam | 92014 + 92134 + 92250 + 92083 | Annually (in addition to injection visits) |
💊 Coding Scenarios
Scenario 1 — First GA Injection Visit, Right Eye (Outpatient)
Clinical Vignette: A 77-year-old female with previously documented intermediate dry AMD (H35.3112) returns for monitoring. Today’s FAF and OCT confirm new geographic atrophy, right eye — 2.3mm² lesion, parafoveal, NOT involving the subfoveal center. Left eye remains intermediate. Decision made to initiate Syfovre (pegcetacoplan) intravitreal injections monthly for the right eye. First injection administered today. Signed informed consent on file.
CPT / HCPCS:
- 67028-RT — Intravitreal injection, right eye (Syfovre administration)
- J2781 × 15 units — Pegcetacoplan 15mg (Syfovre — permanent J-code; 15 units)
- 92134 — OCT posterior segment (GA measurement, subfoveal status confirmation)
- 92250 — Fundus photography with FAF (GA boundary delineation — baseline)
- 92014 — Comprehensive ophthalmological exam, established patient
ICD-10-CM:
- H35.3113 — Nonexudative AMD, right eye, advanced atrophic without subfoveal involvement (progressed from H35.3112 — GA now present, fovea spared; code upgraded from intermediate)
- H35.3122 — Nonexudative AMD, left eye, intermediate dry stage (unchanged)
Stage Code Upgrade — H35.3112 to H35.3113
This is the same documentation imperative as an intermediate-to-advanced transition. The physician’s note must explicitly document:
- GA is present (confirmed on FAF/OCT)
- GA does NOT involve the subfoveal center (confirms H35.3113 over H35.3114)
- Disease progression from prior intermediate stage
Without documentation of the subfoveal status, a CDI query is required before assigning H35.3113. The FAF and OCT reports independently support the subfoveal-sparing status when they document the lesion dimensions and foveal distance.
Scenario 2 — Syfovre Every-Other-Month Injection Visit (Outpatient)
Clinical Vignette: Established H35.3113 patient on Syfovre every-other-month dosing. Returns for scheduled injection. OCT shows stable GA — no progression since last visit. No new subretinal fluid. No complications from prior injection. Injection administered without complication.
CPT / HCPCS:
- 67028-RT — Intravitreal injection, right eye
- J2781 × 15 units — Pegcetacoplan 15mg (15 units — verify units every claim)
- 92134 — OCT posterior segment (GA stability check and safety monitoring)
ICD-10-CM:
- H35.3113 — Nonexudative AMD, right eye, advanced atrophic without subfoveal involvement
OCT at Every GA Injection Visit Is Standard of Care — Bill It
92134 at every GA injection visit is both clinically indicated and separately billable — it is the mechanism by which the physician confirms the GA has not progressed to subfoveal involvement (H35.3114) and checks for injection complications (endophthalmitis, increased IOP, RPE tear). Do not bundle 92134 into the injection visit as “incidental” — it is a separately medically necessary service with its own documentation requirements.
Scenario 3 — H35.3113 Progresses to H35.3114 — Subfoveal Involvement Identified (Outpatient)
Clinical Vignette: Patient on monthly Izervay injections for H35.3113, right eye. At today’s monitoring visit, FAF and OCT confirm geographic atrophy has now extended to involve the subfoveal center, right eye. VA has dropped from 20/40 to 20/160 OD since last visit 6 weeks ago. Treatment decision: continue Izervay injections as GA slowing benefit may still apply even after subfoveal involvement.
CPT / HCPCS:
- 67028-RT — Intravitreal injection, right eye
- J2782 × 20 units — Avacincaptad pegol 2mg (Izervay — 20 units)
- 92134 — OCT posterior segment (subfoveal involvement confirmation)
- 92250 — Fundus photography with FAF (GA lesion re-delineation post-progression)
- 92014 — Comprehensive ophthalmological exam (VA decline assessment, treatment discussion)
ICD-10-CM:
- H35.3114 — Nonexudative AMD, right eye, advanced atrophic WITH subfoveal involvement (progressed from H35.3113 — GA now at foveal center; code upgraded)
- H54.2121 — Low vision, right eye, category 2; left eye normal vision (VA 20/160 OD meets low vision criteria — separately codeable)
This Is the Most Impactful Stage Transition in Dry AMD
The transition from H35.3113 to H35.3114 represents the point of irreversible central vision loss. Once GA involves the subfoveal center, central VA cannot be recovered with any current therapy — treatment shifts from preservation to slowing further progression. Accurate coding of this transition:
- Documents the precise timing of foveal involvement for the medical record
- Triggers assessment of vision impairment codes (H54.xx)
- Supports disability documentation, driving assessment, ADL counseling, and low-vision rehabilitation referral
- Creates an auditable baseline for treatment efficacy measurement (how much did Izervay slow the progression?)
⚠️ Coding Pitfalls and Tips
| Pitfall or Tip | |
|---|---|
| ❌ | Never code H35.3112 when GA is documented — geographic atrophy = advanced AMD; H35.3112 (intermediate) requires no GA; undercoding advanced AMD as intermediate is the #1 documented AMD coding error nationally [web:70] |
| ❌ | Never submit H35.311 (6-character) — non-billable header — H35.3113 (7 characters) required |
| ❌ | Do not assume subfoveal involvement without documentation — the difference between H35.3113 and H35.3114 requires explicit documentation or imaging confirmation; query when absent |
| ❌ | Do not bill J2781 or J2782 without 67028-RT — the GA drug code covers the drug only; the injection procedure must be separately billed |
| ❌ | Do not use wrong unit counts — J2781 = 15 units (Syfovre 15mg); J2782 = 20 units (Izervay 2mg) — unit errors are a top GA drug billing denial cause |
| ❌ | Do not continue coding H35.3113 when subfoveal involvement is documented — upgrade to H35.3114 and add vision impairment codes as applicable |
| ✅ | Read the FAF and OCT reports for subfoveal status — these are the primary sources for the H35.3113 vs H35.3114 distinction; imaging reports make this determination without a physician query in most cases |
| ✅ | Code vision impairment (H54.xx) when VA criteria are met — advanced AMD with measurable VA loss should be coded with the appropriate H54 code; it may serve as a CC in the inpatient setting |
| ✅ | Confirm permanent J-codes are in use — J2781 for Syfovre (since Oct 1, 2023) and J2782 for Izervay (since April 1, 2024); outdated NOC codes (J3490) should not appear on current claims |
| ✅ | Document GA lesion size and foveal distance in physician notes — these findings are what enable accurate H35.3113 vs H35.3114 distinction without a query |
| ✅ | Use bilateral code H35.3133 when both eyes have GA without subfoveal involvement at the same stage; use separate codes when stages or subfoveal status differ between eyes |
📚 Sources
1. CMS/NCHS. ICD-10-CM Official Guidelines for Coding and Reporting, FY2025. Tabular List — H35.311 Nonexudative AMD, 7th character staging instructions. 2. Ferris FL, et al. “Clinical Classification of Age-related Macular Degeneration.” Ophthalmology. 2013;120(4):844-851. 3. JMCP. “Geographic atrophy and factors associated with disease progression.” January 2025. GA progression rate ~1.5-2.5 mm²/year epidemiologic data. [web:114] 4. Optometric Management. “Coding and Billing Updates for Geographic Atrophy Drugs.” 2025. Syfovre J2781 (Oct 2023), Izervay J2782 (April 2024) permanent code assignments. [web:115] 5. Retinal Physician. “Permanent J-code for Izervay Injection.” April 2024. J2782 billing guidance. [web:120] 6. Syfovre Access Support Navigator. “Billing and Coding.” 15 units per Syfovre injection. [web:118] 7. Izervay J-Code Flashcard. J2782, 20 units per 2mg dose. [web:117] 8. PMC/NIH. “Variations in Using Diagnosis Codes for Defining Age-Related Macular Degeneration.” 2024. GA underreporting documentation — incorrect coding as intermediate AMD. [web:70] 9. AAPC. ICD-10 Code H35.3113 — Nonexudative AMD, right eye, advanced atrophic without subfoveal involvement. Confirmed billable FY2025. [web:111]