H35.3222

🧬 ICD-10-CM H35.3222 — Exudative AMD, Left Eye, Inactive CNV

Billable Code — No Warning Needed

ICD-10 CM H35.3222 is a valid, billable, fully specified 7-character ICD-10-CM code for FY2025. All seven characters are present and clinically meaningful: H35 (category) + .3 (degeneration of macula) + 2 (exudative) + 2 (left eye) + 2 (inactive CNV). This is the post-treatment success code — it documents that anti-VEGF therapy has controlled CNV activity and the macula is currently fluid-free.

Non-Billable Parent Codes

• ❌ H35.322 — 6-character header — missing stage character
• ❌ H35.32 — 5-character header — missing laterality AND stage Always submit H35.3222 (all 7 characters) for inactive CNV, left eye.

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🔍 Code Description

H35.3222 classifies exudative (wet) age-related macular degeneration of the left eye with inactive choroidal neovascularization — the stage where CNV vessels are present in the left eye but no longer actively leaking, as confirmed by the absence of subretinal fluid (SRF), intraretinal fluid (IRF), or sub-RPE fluid on OCT at the time of the encounter. [web:152]

H35.3222 represents the treatment success state of wet AMD — the clinical goal of every anti-VEGF injection is to move the patient from H35.3221 (active CNV with fluid) to H35.3222 (inactive CNV, fluid resolved). However, unlike H35.3223 (inactive scar), where CNV has permanently converted to fibrovascular scar, inactive CNV in H35.3222 is a dynamic, reversible state — the CNV membrane remains viable and can reactivate at any time, causing recurrent fluid and requiring the code to revert to H35.3221. This perpetual vigilance — monitoring for reactivation while extending injection intervals — is the defining clinical reality of the H35.3222 stage and the entire Treat-and-Extend (T&E) treatment paradigm. [web:160]

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🌳 Code Tree / Hierarchy — Left Eye Wet AMD Family

H35.32       Exudative AMD   ❌ Non-billable header
│
└── H35.322  Left Eye   ❌ Non-billable header
    │
    ├── H35.3220  Stage unspecified ⚠️ Last resort
    ├── H35.3221  Active CNV ⚡ Ophthalmologic urgency
    ├── H35.3222  INACTIVE CNV ◀ THIS CODE ✅ Treatment success state
    └── H35.3223  Inactive scar — End-stage disciform

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📊 Inactive CNV in Staging Context

Code	Stage	OCT	Fluid?	Anti-VEGF?	Code Stability
H35.3220	Unspecified ⚠️	Unknown	?	Cannot determine	N/A
H35.3221	Active CNV	SRF/IRF/PED/hemorrhage	✅ YES	✅ Inject	Changes with treatment
H35.3222	Inactive CNV ← This Code	Flat, dry macula — CNV membrane visible	❌ NO	T&E or PRN	Reverts to H35.3221 if fluid returns
H35.3223	Inactive scar	Disciform fibrosis	❌ No	Usually stopped	More stable — permanent scar

H35.3222 vs. H35.3223 — The Critical Distinction

Both codes represent “inactive” wet AMD — but they are fundamentally different end states:

Feature	H35.3222 Inactive CNV	H35.3223 Inactive Scar
CNV vessels	Present — quiescent	Replaced by fibrovascular scar
Fluid	None currently	None — scar cannot leak
Reactivation risk	✅ HIGH — can re-activate	❌ Very low — scar is stable
Anti-VEGF continued?	✅ Usually yes — T&E/PRN	❌ Usually stopped
VA trajectory	Stable, possibly improving	Permanently reduced
OCT appearance	Flat macula ± CNV membrane	Hyperreflective subretinal fibrosis

If the physician documents “scar” or “disciform” or “fibrosis” → that’s H35.3223, not H35.3222. If the record shows fluid-free macula with CNV membrane present but no scar → H35.3222. When the distinction is ambiguous, query.

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📋 Clinical Overview — The Treat-and-Extend World of H35.3222

What “Inactive CNV” Means Clinically

At the H35.3222 stage, the patient’s CNV has been suppressed by anti-VEGF treatment to the point where:

• The macula is “dry” — no subretinal, intraretinal, or sub-RPE fluid on OCT
• The CNV membrane may still be visible on OCT-A as a flow signal or hyperreflective material — but it is not actively leaking
• Visual acuity is stable or has improved from the prior active stage
• The patient is no longer in the urgent treatment phase — instead, they are in long-term management aimed at maintaining the dry state while minimizing injection burden

The defining clinical challenge at H35.3222 is answering the question: How long can we safely extend the injection interval before fluid returns? This question drives the entire Treat-and-Extend protocol — the dominant treatment paradigm for wet AMD in modern retina practice.

The Treat-and-Extend Protocol — How It Creates H35.3222 Encounters

Treat-and-Extend (T&E), first described by Spaide and Freund, is the most widely used anti-VEGF strategy in wet AMD management: [web:160]

LOADING PHASE (H35.3221 — Active CNV)
Monthly injections × 3 until OCT shows DRY MACULA
            │
            ▼ Macula dry = Fluid resolved = CODE SHIFTS TO H35.3222
EXTENSION PHASE (H35.3222 — Inactive CNV)
Inject at THIS visit (preventive) + EXTEND interval by 2 weeks
            │
     Next visit (extended interval):
            ├── Still dry → inject + extend again (H35.3222 continues)
            ├── Still dry → inject + extend to max interval (H35.3222 continues)
            │         (Maximum interval: typically 12-16 weeks per drug)
            │
            └── FLUID RETURNS → H35.3221 (Active CNV — reactivation)
                  Shorten interval → treat back to dry → H35.3222 again

The T&E Injection at an H35.3222 Visit — Fully Billable

One of the most important billing nuances at this stage: under T&E protocol, the physician injects at the H35.3222 visit even though the macula is currently dry — the injection is preventive, to maintain the extended interval and prevent fluid recurrence. This injection is fully billable with H35.3222 as the supporting diagnosis.

Common coder misconception: “If there’s no fluid, there’s no active disease, so the injection isn’t medically necessary.” This is incorrect. T&E injection at H35.3222 is medically necessary and payer-supported because:

• Discontinuing anti-VEGF in inactive wet AMD leads to rapid reactivation in the majority of patients
• Maintaining the extended T&E interval preserves vision and reduces reactivation risk
• All major MACs and commercial payers recognize T&E as standard of care for wet AMD

The medical necessity documentation should explicitly state the T&E protocol rationale — e.g., “Wet AMD, left eye, currently inactive on T&E — macula dry — injecting to maintain treatment interval — extending to 10 weeks.”

PRN (Pro Re Nata / As-Needed) Protocol — The Alternative

Under the PRN protocol (less common than T&E but still used): [web:109]

LOADING PHASE (H35.3221 — Active CNV)
Monthly injections × 3 until macula dry
            │
            ▼ CODE SHIFTS TO H35.3222
PRN MONITORING PHASE (H35.3222 — Inactive CNV)
Monthly OCT — NO INJECTION given if macula is dry
            │
     At each monthly monitoring visit:
            ├── Dry → H35.3222 — no injection — monitoring visit only
            │
            └── FLUID RETURNS → H35.3221 → inject → back to monitoring

PRN vs. T&E — The Coding Is the Same, the Billing Is Different

Both PRN and T&E result in H35.3222 when the macula is dry. The coding is identical. The billing difference is:

• T&E dry visit → injection IS given → bill 67028-LT + J-code + 92134 + 92014
• PRN dry visit → injection NOT given → bill 92134 + 92014 only (no injection CPT or drug J-code)

The claim volume for T&E is higher than PRN, even when both eyes are equally controlled, because T&E injects regardless of fluid status under the preventive protocol. Both are clinically legitimate and payer-supported.

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🔍 OCT at H35.3222 — What You’re Looking For

The OCT report at an H35.3222 encounter should confirm a dry macula — the absence of all active fluid markers:

OCT Feature	H35.3222 Expected Finding	Alert: Consider H35.3221 If
Subretinal fluid (SRF)	❌ Absent	Any SRF present
Intraretinal fluid (IRF)	❌ Absent	Any cystoid spaces
Sub-RPE fluid / PED	❌ Absent or stable chronic PED (non-leaking)	New or enlarging PED
SHRM (subretinal hyperreflective material)	May be present as stable treated membrane	New SHRM or growing SHRM
Subretinal hemorrhage	❌ Absent	Any new hemorrhage
CNV membrane (OCT-A)	May be visible as stable flow signal	New enlargement of flow signal
Central retinal thickness (CRT)	Stable or improving from prior active phase	New CRT increase ≥ 15-25μm

The Stable PED Problem — H35.3222 or H35.3221?

Pigment epithelial detachments (PEDs) are a common source of ambiguity in wet AMD activity coding. A patient may have a stable, chronic fibrovascular PED under the RPE that does not represent active CNV leakage — this is H35.3222 territory. However, a new or enlarging PED with increasing sub-RPE fluid may represent active CNV → H35.3221. The key is the physician’s documentation of whether the PED is stable and unchanged vs. new or growing. When the record says “stable PED, no active fluid” → H35.3222. When it says “enlarging PED with sub-RPE fluid” or “symptomatic PED” → query or H35.3221 based on context.

OCT Coding Updates for 2025 — What Changed

92134 OCT Code — 2025 Changes

The OCT code family underwent revisions at the start of 2025. [web:155] Key points for H35.3222 monitoring visits:

• 92134 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral — remains the primary code for macular OCT in wet AMD monitoring
• New for 2025: Additional OCT-A (optical coherence tomography angiography) code clarifications; confirm your payer’s current LCD for OCT-A coverage under H35.3222
• Bilateral OCT remains billable as a single 92134 code with documentation of both eyes — payer policies on billing one vs. two units for bilateral OCT have been updated; verify your MAC’s current guidance

Always check the current Retina Today OCT coding updates (published annually) for the most current 92134 billing guidance, as this is one of the most frequently revised outpatient retina billing areas.

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💰 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

No direct HCC weight — consistent across all H35.32x codes. The monthly or near-monthly encounter frequency under T&E protocol creates repeated comorbidity capture opportunities. Every H35.3222 monitoring or injection visit is a touchpoint for documenting diabetes, cardiovascular disease, CKD, and other RAF-bearing comorbidities.

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🏥 MS-DRG Assignment

MDC 02 — Diseases and Disorders of the Eye (if principal — extremely rare)

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.

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🔗 Related ICD-10-CM Codes

Complete Left-Eye Wet AMD Staging

Code	Stage	Fluid?	Anti-VEGF?	Reactivation Risk?
H35.3220	Unspecified ⚠️	?	Cannot determine	Unknown
H35.3221	Active CNV	✅ YES	✅ Inject urgently	N/A — currently active
H35.3222	Inactive CNV ← This Code	❌ NO	T&E or PRN	✅ High — monitor closely
H35.3223	Inactive scar	❌ No	Usually stopped	Low — scar is stable

Bilateral Equivalents

Code	Description	Use When
H35.3232	Exudative AMD, bilateral, inactive CNV	Both eyes inactive CNV at same visit
H35.3222 + H35.3212	Left inactive + right inactive	Both eyes inactive — separate codes also acceptable

Asymmetric Stage Combinations — Left Eye Inactive + Right Eye

Right Eye Status	Right Eye Code	Coding Action
Active CNV	H35.3211	Separate codes — left inactive H35.3222 + right active H35.3211
Inactive CNV	H35.3212	Both inactive — use bilateral H35.3232 or separate codes
Inactive scar	H35.3213	Separate codes — different end stages
Dry AMD (any stage)	H35.311x	Separate codes — different disease type

Commonly Co-Coded

Code	Description	When
H54.8	Legal blindness	If VA ≤20/200 better eye — persists even when CNV inactive
H54.12x	Blindness, left eye	VA ≤20/200 left eye — prior active CNV may have caused permanent damage
Z82.1	Family history of blindness	Ongoing risk documentation
F32.9	Major depressive disorder	Vision loss and injection burden — ongoing risk even at stable stage

Vision Impairment Codes Persist at H35.3222 — Don't Drop Them

A patient who had H54.8 (legal blindness) assigned when their CNV was active (H35.3221) may still meet legal blindness criteria even after CNV becomes inactive (H35.3222) — because the prior active CNV may have caused permanent photoreceptor damage that persists even after fluid resolution. Always reassess VA at each encounter. If VA remains ≤20/200, continue coding H54.8 alongside H35.3222. Do not automatically drop vision impairment codes simply because the CNV is now inactive.

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🛠️ CPT / HCPCS — H35.3222 Encounter Templates

Template A: T&E Injection Visit — Inactive CNV, Preventive Injection Given

Type	Code	Modifier(s)	Description
Exam	92014	—	Established comprehensive exam
OCT	92134	—	Confirms dry macula — required
Injection procedure	67028	-LT	Intravitreal injection, left eye — T&E preventive dose
Drug: Vabysmo	J2777 × 60	-LT -JZ	Faricimab-svoa 6mg, no waste
Drug: Eylea 2mg	J0178 × 1	-LT -JZ	Aflibercept 2mg, no waste
Drug: Eylea HD	J0179 × 1	-LT -JZ	Aflibercept 8mg — extended interval T&E
Drug: Lucentis	J2778 × 5	-LT -JZ	Ranibizumab 0.5mg, no waste
Diagnosis	H35.3222	—	Inactive CNV — current OCT dry — T&E protocol

Medical Necessity Documentation Template for T&E H35.3222 Injection

The physician’s note must explicitly support injection at an inactive-CNV visit. A strong documentation template:

“Left eye: Exudative AMD with CNV — currently INACTIVE on treat-and-extend protocol. OCT today: macula dry, no SRF, no IRF, no new hemorrhage. CRT [X]μm, stable. CNV membrane present on OCT-A, quiescent. VA: 20/[X] OS. Injecting today per T&E protocol to maintain [X]-week interval and prevent reactivation. Extending to [X+2]-week interval at next visit. Medical necessity: discontinuation of anti-VEGF in inactive wet AMD carries significant reactivation risk; T&E injection maintains CNV suppression.”

Template B: PRN Monitoring Visit — Inactive CNV, No Injection

Type	Code	Modifier(s)	Description
Exam	92014	—	Established comprehensive exam
OCT	92134	—	Confirms dry macula — primary monitoring tool
FA (if needed)	92235	—	Only if reactivation suspected or interval change considered
Diagnosis	H35.3222	—	Inactive CNV — PRN monitoring — no fluid today

No Injection at PRN Monitoring Visit — No 67028, No J-Code

At a PRN monitoring visit where the OCT is dry and no injection is given, do not bill 67028 or any drug J-code. The claim is simply the exam (92014) + OCT (92134) + H35.3222 as the diagnosis. This is expected for PRN protocol and will not trigger a denial — it reflects appropriate clinical decision-making: observed, no fluid, no injection needed today.

Template C: Monitoring Visit — Fluid Detected — Code Shifts

Mid-Visit Code Change — OCT Shows New Fluid

If the patient presents for a scheduled H35.3222 monitoring or T&E visit and OCT reveals new or recurrent fluid — the code for this visit changes to H35.3221 (active CNV), the physician injects, and the injection is fully supported by the active diagnosis.

Type	Code	Notes
Exam	92014	Extended — reactivation discussion
OCT	92134	Documents fluid recurrence
FA	92235	Consider if hemorrhage or new CNV type
Injection	67028-LT	Active CNV confirmed → inject
Drug	J-code -LT-JZ	Anti-VEGF agent
Diagnosis	H35.3221	NOT H35.3222 — fluid present = active CNV

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💊 Coding Scenarios

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Scenario 1 — Established T&E Patient, Dry at 10-Week Visit (Outpatient)

Clinical Vignette: A 77-year-old female with wet AMD left eye on Vabysmo T&E protocol. Last visit: 8 weeks ago — fluid resolved, extended to 10-week interval. Today at 10 weeks: OCT left eye — completely dry. No SRF, no IRF. CRT 235μm (stable). VA: 20/40 OS. Physician documents: “Wet AMD left eye, inactive — macula dry on OCT — excellent response — Vabysmo injection given today — extending to 12 weeks.” Vabysmo 6mg administered.

CPT / HCPCS:

• 92014 — Comprehensive ophthalmological exam, established
• 92134 — OCT posterior segment (dry macula confirmed — required at every injection visit)
• 67028-LT — Intravitreal injection, left eye
• J2777-LT-JZ × 60 units — Vabysmo 6mg, no waste

ICD-10-CM:

• H35.3222 — Exudative AMD, left eye, inactive CNV (OCT dry — CNV currently quiescent — T&E injection to maintain suppression)

This Is the Classic H35.3222 T&E Scenario

This scenario repeats every 8-16 weeks throughout the patient’s lifetime of wet AMD management. The code is H35.3222 at every dry-macula T&E visit, regardless of how many years the patient has been on treatment or how many injections they have received.

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Scenario 2 — PRN Protocol, Bilateral Wet AMD — Different Activity Status Each Eye (Outpatient)

Clinical Vignette: A 74-year-old male with bilateral wet AMD on PRN monitoring. Today: OCT right eye — subretinal fluid present, new — physician injects right eye. OCT left eye — completely dry, unchanged from last visit — no injection left eye. VA: 20/80 OD (decreased), 20/35 OS.

CPT / HCPCS:

• 67028-RT — Intravitreal injection, right eye only
• J0178-RT-JZ × 1 — Eylea 2mg, right eye, no waste
• 92134 — OCT, bilateral (both eyes documented)
• 92014 — Comprehensive exam, established

ICD-10-CM:

• H35.3211 — Exudative AMD, right eye, active CNV (new SRF today — active at this visit)
• H35.3222 — Exudative AMD, left eye, inactive CNV (dry on OCT — no injection left eye today)

Asymmetric Activity Status — Separate Codes, One Visit

This is a perfect example of why bilateral wet AMD codes (H35.3231/H35.3232) are not always appropriate — the eyes are at different activity stages on the same day. Right eye is active (H35.3211) requiring injection; left eye is inactive (H35.3222) requiring only monitoring. Two separate laterality-specific codes correctly represent the clinical picture. The claim shows injection CPT + J-code for right eye only, with both AMD codes as diagnoses.

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Scenario 3 — H35.3222 Becomes H35.3223 — Scar Formation (Outpatient)

Clinical Vignette: A 86-year-old male with longstanding wet AMD left eye — on quarterly Vabysmo T&E. Today: OCT left eye — no fluid — but new extensive subretinal fibrosis replacing the prior CNV membrane location — physician documents: “Disciform scar developing, left eye — inactive wet AMD progressing to scar formation — transitioning off anti-VEGF — low vision referral.” No injection today.

ICD-10-CM — Code Change:

• H35.3223 — Exudative AMD, left eye, inactive scar (scar now documented → retire H35.3222 for this eye; H35.3223 is the new permanent code)
• H54.8 — Legal blindness (if VA ≤20/200 — common at disciform scar stage)

H35.3222 Retires When Scar Forms — Assign H35.3223 Going Forward

Once the physician documents disciform scar or subretinal fibrosis replacing the CNV membrane, transition from H35.3222 to H35.3223 permanently for that eye. The two codes are not interchangeable — H35.3222 implies active CNV that is controllable with anti-VEGF; H35.3223 implies the CNV has burned out and been replaced by scar. Do NOT continue coding H35.3222 after scar is documented, as this would misrepresent the clinical end-stage status of the eye.

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Scenario 4 — H35.3222 in the Inpatient Setting (Inpatient Admission)

Clinical Vignette: A 79-year-old female admitted for hip fracture. H&P documents wet AMD, left eye, on monthly Eylea — “currently controlled, last injection 3 weeks ago — scheduled for injection in 1 week at outpatient retina practice.” OCT not performed during admission. VA OS: 20/50.

Additional Diagnosis:

• H35.3222 — Exudative AMD, left eye, inactive CNV (physician documents “currently controlled” — inactive status at admission — meets UHDDS criteria as active chronic condition affecting discharge planning and ophthalmology follow-up coordination)

"Currently Controlled" = Inactive CNV = H35.3222

When the H&P or attending note documents wet AMD as “currently controlled,” “on maintenance injections,” or “stable on anti-VEGF,” this language supports H35.3222 (inactive CNV) — not H35.3221 (active CNV). The inpatient coding goal is to capture the current active status of the condition as documented at admission. “Controlled” and “stable” = inactive. If the note says “active” or OCT shows fluid → H35.3221.

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⚠️ Coding Pitfalls and Tips

	Pitfall or Tip
❌	Never carry H35.3222 forward when current OCT shows fluid — any fluid = H35.3221 active; check every visit’s OCT before assigning
❌	Never assume H35.3222 means no injection should be billed — T&E injections at dry-macula visits are fully billable and medically necessary [web:109]
❌	Never use H35.3222 when scar is documented — scar = H35.3223; they are not interchangeable
❌	Never use bilateral code H35.3232 when the two eyes have different activity stages — separate laterality codes required
❌	Never drop vision impairment codes (H54.8, H54.12x) just because CNV is now inactive — prior damage may persist
✅	Read the OCT every visit — dry macula = H35.3222; any fluid = H35.3221; scar = H35.3223
✅	Document T&E rationale at every inactive injection visit — “injecting to maintain T&E interval and prevent reactivation” is the medical necessity anchor
✅	“Currently controlled” / “stable” / “quiescent” language in H&P → H35.3222 in inpatient setting
✅	PRN monitoring visit with no injection → 92014 + 92134 + H35.3222 — no 67028, no J-code
✅	Code changes dynamically — H35.3221 ↔ H35.3222 may alternate many times over the course of treatment; each visit stands alone
✅	Use H35.3232 when both eyes are confirmed inactive at the same visit — cleaner than two separate codes when both are documented identical
✅	Check OCT 2025 updates — 92134 billing rules were revised; verify bilateral OCT unit billing with your MAC [web:155]

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📚 Sources

1. AAPC. “ICD-10 Code H35.3222 — Exudative AMD, left eye, with inactive choroidal neovascularization.” Confirmed billable FY2025. Left-eye wet AMD staging family H35.3220-H35.3223. [web:151][web:153]

2. Unbound Medicine ICD-10-CM. H35.3222 — Exudative AMD, left eye, with inactive CNV. Code description and tabular structure confirmation. [web:152]

3. FHCP / ICD-10 Update Oct 1, 2016. Original implementation of H35.3221-H35.3223 left-eye wet AMD staging codes, including H35.3222 inactive CNV. [web:154]

4. GenHealth.ai. H35.3221 — Left-eye wet AMD family. H35.3222 listed as inactive CNV equivalent; bilateral code H35.3232 confirmed. [web:144]

5. Retinal Physician. “Coding Q&A: Coding Guidelines for Wet AMD.” Anti-VEGF injection at inactive CNV T&E visit — medical necessity framework; H35.322x staging guidance; OCT requirement at every injection visit. [web:109]

6. Ophthalmology Management. “The Treat-and-Extend Approach to Wet AMD.” T&E history — Spaide and Freund protocol; 78% ASRS adoption rate; OCT dry macula definition; interval extension algorithm; recurrent wet AMD defined as any OCT fluid. [web:160]

7. Retina Today. “OCT: What to Know for 2025.” 92134 OCT code family updates effective 2025; bilateral OCT billing policy changes; OCT-A coverage considerations. [web:155]

8. PMC / LUCAS trial. “Beyond Longer Intervals: Advocating for Regular Treatment.” T&E vs. PRN outcomes comparison; reactivation rates with T&E discontinuation. [web:156]