Crystal's MCW Coder Hub🧬 ICD-10 CM H35.371 — Puckering of Macula, Right Eye
Quick Reference
Code: H35.371 | Billable: Yes | Chapter: 7 — Eye and Adnexa | HCC: No | Laterality: Right eye required
Description
ICD-10-CM H35.371 represents puckering of the macula of the right eye — a condition in which a fibrocellular proliferative membrane (epiretinal membrane, ERM) forms on the inner retinal surface overlying the macula. Contraction of this membrane causes tangential traction on the underlying retina, producing the characteristic wrinkling, distortion, and “puckered” appearance of the macular architecture on fundus examination and optical coherence tomography (OCT).
Also known as: epiretinal membrane (ERM), macular pucker, cellophane maculopathy, surface wrinkling retinopathy, and preretinal fibrosis. All of these clinical terms map to H35.371 when affecting the right eye.
ERM may be idiopathic (most common, occurring in older adults as a result of posterior vitreous detachment and subsequent glial cell migration) or secondary to an identifiable cause such as retinal detachment repair, laser photocoagulation, cryotherapy, retinal vascular disease, uveitis, or trauma. Secondary ERM should be coded with an additional code identifying the underlying condition when documented.
Code Structure & Hierarchy
Code Tree
- Chapter: 7 — Diseases of the Eye and Adnexa (H00-H59)
- Block: H30-H36 — Disorders of Choroid and Retina
- H35 — Other retinal disorders
- H35.3 — Degeneration of macula and posterior pole ← this branch
- H35.30 — Unspecified macular degeneration
- H35.31 — Nonexudative (dry) AMD
- H35.32 — Exudative (wet) AMD
- H35.33 — Angioid streaks of macula
- H35.34 — Macular cyst, hole, or pseudohole
- H35.35 — Cystoid macular degeneration
- H35.36 — Drusen (degenerative) of macula
- H35.37 — Puckering of macula ← this subcategory
- H35.38 — Toxic maculopathy
Laterality Requirement
Instructional Notes
Excludes2 — Not Included Here, May Co-exist
The following may be coded in addition to H35.371 when both conditions are separately present and documented:
- Macular cyst, hole, or pseudohole, right eye (H35.341) — may coexist with ERM; ERM can cause pseudohole appearance; query provider for distinction
- Cystoid macular edema (H35.811) — may develop secondary to ERM traction; separately reportable when documented
- Diabetic macular edema (E11.3211 and related) — diabetic CME may coexist with secondary ERM in diabetic patients
- Pucker following retinal detachment repair — code both H35.371 and the underlying condition (e.g., post-surgical complication code or history of retinal detachment)
Use Additional Code
When ERM is secondary in etiology, code the underlying or associated condition:
- Post-surgical ERM → H59.811 — Chorioretinal scars after surgery for detachment, right eye
- History of retinal detachment → H33.001 or applicable H33 code
- Post-inflammatory ERM → applicable H30.- uveitis/chorioretinitis code
- Post-photocoagulation → H59.811 or applicable H59 complication code
- Vitreous degeneration / PVD → H43.891 — Vitreous degeneration, right eye (when PVD is separately documented)
Clinical Description
Macular puckering results from the proliferation of fibrous or glial cells on the inner limiting membrane (ILM) of the retina at the macula. The process is most commonly initiated by posterior vitreous detachment (PVD), during which the vitreous separates from the retinal surface, leaving behind clusters of glial cells (Müller cells, astrocytes, retinal pigment epithelial cells, macrophages) that subsequently proliferate and form the epiretinal membrane. The membrane contracts over time, exerting centripetal tangential traction on the macula and distorting the underlying retinal architecture.
Stages of ERM / macular puckering:
- Cellophane maculopathy (mild): Thin, transparent, reflective membrane on the macular surface; may be asymptomatic or cause mild metamorphopsia; ILM reflex increased on fundus exam; OCT shows mild surface irregularity
- Macular pucker (moderate to severe): Thicker membrane with greater contraction; significant macular distortion, wrinkling, folding of retinal layers; pseudohole formation possible; reduced visual acuity; notable metamorphopsia
- Tractional changes: In advanced disease, ERM contraction may create tractional retinoschisis, epiretinal traction leading to subretinal fluid, or rarely a lamellar or full-thickness macular hole
Clinical presentation:
- Metamorphopsia (distortion of straight lines — detected by Amsler grid) — often the presenting symptom
- Blurred central vision — variable severity; may be mild in cellophane maculopathy, significant in advanced pucker
- Monocular diplopia — less common; from significant macular distortion
- Micropsia — objects appear smaller than normal
- Reduced contrast sensitivity
- Asymptomatic — discovered incidentally on dilated fundus exam or OCT in early stages
Diagnostic workup:
- OCT (optical coherence tomography): Gold standard — shows hyperreflective band on inner retinal surface, macular thickening, loss of foveal contour, intraretinal cysts if present
- Fundus photography: Documents extent and progression; cellophane sheen visible on photography
- Fluorescein angiography (FA): May show late leakage if associated vascular pathology; not required for ERM diagnosis but useful to evaluate coexisting conditions
- Amsler grid: Patient self-monitoring tool for metamorphopsia
Etiology classification:
- Idiopathic ERM (most common) — related to PVD; no identifiable underlying cause
- Secondary ERM — post-retinal detachment repair (scleral buckle, vitrectomy, pneumatic retinopexy), retinal laser/cryotherapy, uveitis, vascular occlusions, trauma, diabetic retinopathy
Coding Guidelines
Official Guideline Reference
ICD-10-CM Official Guidelines FY2025, Section I.C.7 — Diseases of the Eye and Adnexa
- Assign codes from Chapter 7 for conditions documented by an ophthalmologist or supported by clinical findings in the ophthalmic record. Laterality must be coded to the highest level of specificity.
- When ERM is secondary to a prior procedure or condition, the underlying or causative condition should be coded in addition to H35.371.
- Do not assign H35.341 (macular cyst, hole, or pseudohole) simultaneously with H35.371 without provider confirmation that both conditions are distinctly present — OCT interpretation by the provider should drive code selection when pseudohole vs. true ERM-related distortion is ambiguous.
Sequencing Tips
- Outpatient — First-listed diagnosis: H35.371 when macular pucker/ERM is the primary reason for the encounter (clinic visit, surgical consult, pre-op evaluation)
- Secondary diagnosis: When patient presents for a different primary ocular condition (e.g., AMD, glaucoma) and ERM is also documented and addressed, H35.371 is coded as an additional diagnosis
- Post-operative encounters: If ERM develops or is monitored after vitrectomy for another indication, sequence the primary reason for the post-op visit first; H35.371 may be additional
- Surgical encounter: H35.371 as first-listed when vitrectomy with membrane peel (67041 or 67042) is the primary procedure
- POA (inpatient): H35.371 is almost always Y — macular pucker is a chronic/progressive condition present before admission. Development of ERM as a complication of inpatient surgery would be POA = N.
HCC Mapping
HCC Risk Adjustment
HCC Relevant: No HCC Model: CMS-HCC v28 HCC Category: Not mapped HCC Coefficient: 0.000 Risk Adjustment Impact: None
H35.371 does not carry HCC weight under CMS-HCC v28. It does not contribute to Medicare Advantage risk scores. However, associated comorbidities that may co-exist (e.g., diabetic retinopathy E11.3211, exudative AMD H35.3211) carry significant HCC weight and should be coded separately when present.
Associated HCC Opportunities
While H35.371 itself has no HCC mapping, the following commonly associated conditions do — always code them when present and documented:
MS-DRG Mapping
DRG Assignment
MS-DRG Description MDC GMLOS 124 Other Disorders of the Eye with MCC MDC 2 4.6 125 Other Disorders of the Eye with CC or without CC/MCC MDC 2 3.1
CC/MCC Status
- CC status: No — H35.371 does not function as a CC or MCC
- MCC status: No
- HAC designation: No
- POA exempt: No
- Inpatient note: Inpatient admission solely for macular puckering is rare. Vitrectomy with membrane peel is overwhelmingly performed in the ASC/outpatient setting. When H35.371 appears in the inpatient setting, it is typically a secondary diagnosis alongside a primary condition (e.g., retinal detachment, endophthalmitis). DRG assignment will be driven by the principal diagnosis and any CC/MCC secondary diagnoses.
CPT Crosswalk
| CPT | Description |
|---|---|
| 67041 | Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (e.g., macular pucker) |
| 67042 | Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of the retina (e.g., for repair of macular hole, macular puckering) |
| 67043 | Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (e.g., choroidal neovascularization) |
| 67228 | Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation |
| 92134 | Scanning computerized ophthalmic diagnostic imaging, posterior segment (OCT), with interpretation and report, unilateral or bilateral |
| 92250 | Fundus photography with interpretation and report |
| 92225 | Ophthalmoscopy, extended, with retinal drawing, initial |
| 92226 | Ophthalmoscopy, extended, with retinal drawing, subsequent |
CPT 67041 vs 67042
- 67041 — Vitrectomy with removal of preretinal cellular membrane (ERM/macular pucker peel) — use when the primary procedure is ERM removal without ILM peel
- 67042 — Vitrectomy with removal of internal limiting membrane (ILM) — use when ILM peel is performed (typically for macular hole repair but also used in ERM surgery to reduce recurrence)
- When both ERM and ILM are peeled during the same session, 67042 is the appropriate code — it represents the more complex procedure; do not bill both 67041 and 67042 together
ICD-10-PCS Crosswalk
PCS Applicability
ICD-10-PCS applies in the inpatient setting only. Vitrectomy with membrane peel for macular puckering is rarely performed inpatient but is documented here for completeness.
| PCS Code | Root Operation | Body Part | Approach | Device | Qualifier |
|---|---|---|---|---|---|
| 08B33ZZ | Excision | Vitreous, Right | Percutaneous | No Device | No Qualifier |
| 08N33ZZ | Release | Vitreous, Right | Percutaneous | No Device | No Qualifier |
Character breakdown — vitrectomy with ERM peel, right eye (08N33ZZ):
- Section: 0 — Medical and Surgical
- Body System: 8 — Eye
- Root Operation: N — Release (freeing a body part from abnormal physical constraint; membrane peel = release of macular traction)
- Body Part: 33 — Vitreous, Right
- Approach: 3 — Percutaneous (pars plana approach)
- Device: Z — No Device
- Qualifier: Z — No Qualifier
Root Operation Note
PCS Root Operation for ERM peel may be coded as N — Release (releasing the macula from the constraining epiretinal membrane) or B — Excision (removing the membrane tissue). Provider and coder collaboration is recommended to select the root operation that best reflects the operative note’s description of the procedure.
ICD-10-CM Crosswalk
| Code | Description | Relationship |
|---|---|---|
| H35.372 | Puckering of macula, left eye | Contralateral equivalent |
| H35.373 | Puckering of macula, bilateral | Bilateral equivalent |
| H35.379 | Puckering of macula, unspecified eye | Less specific — avoid if laterality documented |
| H35.341 | Macular cyst, hole, or pseudohole, right eye | Related macular pathology — may coexist; Excludes2 |
| H35.351 | Cystoid macular degeneration, right eye | May co-occur — CME secondary to ERM traction |
| H35.361 | Drusen of macula, right eye | May co-occur — AMD-related drusen alongside ERM |
| H35.3211 | Exudative AMD, right eye, with active CNV | Co-occurring condition — code separately when present |
| H33.001 | Unspecified retinal detachment with rhegmatogenous defect, right eye | Common precursor or associated condition |
| H43.891 | Vitreous degeneration, right eye | PVD — common antecedent to idiopathic ERM |
| H59.811 | Chorioretinal scars after surgery for detachment, right eye | Secondary ERM after retinal surgery |
| H26.411 | Combined forms of age-related cataract, right eye | Frequent comorbidity in ERM surgical candidates |
| E11.3211 | Type 2 diabetes with mild NPDR, right eye, without macular edema | Common comorbidity — secondary ERM etiology |
| Z96.1 | Presence of intraocular lens | Prior cataract surgery — relevant surgical history |
Coding Examples
Example 1 — Idiopathic Macular Pucker, Right Eye, Surgical Consultation, Outpatient
Scenario: A 67-year-old patient presents to retina specialist with a 6-month history of progressive metamorphopsia and blurry central vision in the right eye. OCT demonstrates a thick epiretinal membrane with significant macular distortion and loss of foveal contour. Best corrected visual acuity is 20/80 right eye. No identifiable secondary cause — documented as idiopathic ERM. Surgeon recommends pars plana vitrectomy with membrane peel. Extended ophthalmoscopy with retinal drawing performed. First-listed Dx: H35.371 — Puckering of macula, right eye CPT: 92225 — Extended ophthalmoscopy, initial; 92134 — OCT posterior segment with interpretation Modifiers: -RT Notes: Idiopathic ERM — no additional etiology code required. Document BCVA, metamorphopsia severity, and OCT findings in the note to support medical necessity for surgical planning.
Example 2 — Secondary ERM Right Eye After Retinal Detachment Repair, Pre-op Vitrectomy
Scenario: A 59-year-old patient who underwent scleral buckle repair for right rhegmatogenous retinal detachment 18 months prior now presents with macular pucker of the right eye confirmed on OCT. Surgeon documents preretinal membrane formation secondary to prior retinal detachment surgery. Vitrectomy with ERM peel is planned. Fundus photography and OCT performed at this visit. First-listed Dx: H35.371 — Puckering of macula, right eye (primary reason for encounter) Additional Dx: H59.811 — Chorioretinal scars after surgery for detachment, right eye (secondary etiology) CPT: 92134 — OCT posterior segment; 92250 — Fundus photography Notes: Secondary ERM should always carry the etiologic condition as an additional code. H59.811 documents the post-surgical origin and supports medical necessity narrative.
Example 3 — Vitrectomy with ERM Peel and ILM Peel, Right Eye, ASC Setting
Scenario: Patient with previously documented right eye macular pucker (H35.371) and visual acuity of 20/100 undergoes pars plana vitrectomy with combined ERM and ILM peel under local anesthesia in an ASC. The operative note documents removal of the epiretinal membrane followed by peeling of the internal limiting membrane to reduce recurrence. Cataract (posterior subcapsular) also noted but not treated at this session. First-listed Dx: H35.371 — Puckering of macula, right eye Additional Dx: H26.411 — Combined forms of age-related cataract, right eye (documented, not treated) CPT: 67042-RT — Vitrectomy with removal of ILM (the more complex procedure encompassing both ERM and ILM peel; do not bill 67041 and 67042 together) Notes: When both ERM and ILM are removed, 67042 is the correct single code — it subsumes 67041. Modifier -RT required. Document lens status (phakic/pseudophakic) in operative report as it affects surgical complexity and future cataract coding.
Coding Pitfalls & Tips
Common Errors
- Using H35.379 (unspecified eye) when laterality is clearly documented — always assign H35.371 (right) or H35.372 (left) when specified
- Billing 67041 and 67042 together for the same eye on the same date — when both ERM and ILM are peeled, 67042 is the single appropriate code; dual billing will trigger NCCI edit denial
- Failing to code the secondary etiology when ERM is post-surgical or post-inflammatory — missing the additional code leaves the clinical picture incomplete and may affect payer medical necessity review
- Confusing macular pucker (H35.371) with macular hole (H35.341) — OCT is definitive; macular pucker involves a membrane on the retinal surface causing traction and distortion; macular hole is a full-thickness or partial-thickness defect through the foveal tissue. These are distinct conditions with different surgical approaches.
- Coding H35.351 (cystoid macular degeneration) when cystoid macular edema (H35.811) is what is present — cystoid macular degeneration is a degenerative/atrophic process; CME is edematous fluid accumulation, often secondary to surgery or inflammation
- Not capturing associated conditions (drusen, AMD, diabetic retinopathy) that are documented in the same encounter — missed HCC and clinical documentation opportunity
Pro Tips
- OCT reports are the primary documentation source for H35.371 — ensure the interpreting provider signs the OCT interpretation report and links findings to the diagnosis in the assessment plan
- When cellophane maculopathy (very mild, transparent ERM) is documented without significant visual disturbance, H35.371 is still appropriate — there is no separate code for early vs. advanced ERM in ICD-10-CM; severity is captured through visual acuity documentation and clinical note narrative
- For bilateral ERM documented at the same encounter, use H35.373 — not two separate codes (H35.371 + H35.372). Bilateral code is available and preferred when both eyes are affected at the same visit
- PVD (H43.891) is frequently documented alongside idiopathic ERM — code separately when it is documented as a distinct active finding, not just a historical antecedent
- In the pre-op setting, document BCVA, Amsler grid results, OCT membrane thickness, and degree of visual impairment — these support medical necessity for 67041/67042 and protect against payer denial for “mild” ERMs where surgery may be questioned
CDI Query Opportunities
CDI Flags
- Laterality confirmation: Is the right eye the only affected eye? If OCT shows bilateral ERM (even if one side is asymptomatic), query for bilateral documentation → H35.373
- Etiology clarification: Is the ERM idiopathic or secondary? If there is a history of retinal detachment repair, laser, cryotherapy, uveitis, or trauma, query the provider to explicitly link the ERM to the prior condition — the additional code for secondary etiology supports fuller clinical documentation
- Coexisting macular pathology: Is there also a pseudohole, lamellar hole, or CME? Query the provider to distinguish ERM-related pseudohole from a true macular hole (H35.341) — the distinction changes the surgical approach and coding
- Cystoid macular edema: Is there OCT evidence of intraretinal cysts or subretinal fluid? If yes, query whether H35.811 (CME) is also present as a separate diagnosis
- Associated AMD or diabetic retinopathy: Are drusen (H35.361), AMD (H35.3211), or diabetic retinopathy (E11.3211) documented in the same eye? These should be coded separately and carry HCC weight — confirm they appear in the provider’s assessment, not just in the OCT or imaging report
- Vitreous status: Is PVD documented? (H43.891) — relevant to etiology and surgical planning; separately codable when documented as an active finding
- Lens status: Is the patient phakic, pseudophakic, or aphakic? This affects surgical complexity documentation and future cataract surgery coding (Z96.1 for pseudophakia)
Related Codes
- Laterality family: H35.372, H35.373, H35.379
- Related macular conditions: H35.341, H35.351, H35.361, H35.811
- AMD crosswalk: H35.3111, H35.3211
- Secondary etiology codes: H59.811, H33.001, H43.891
- Diabetic eye disease: E11.3211, E11.3511
- CPT crosswalk: 67041, 67042, 92134, 92250, 92225, 92226
- PCS crosswalk: 08B33ZZ, 08N33ZZ
Sources
ICD-10-CM Official Guidelines for Coding and Reporting FY2025. CMS/NCHS. ICD-10-CM Tabular List of Diseases and Injuries FY2025. CMS. CMS MS-DRG Definitions Manual v42. Centers for Medicare & Medicaid Services. CMS-HCC Risk Adjustment Model v28 Coefficients and Category Mappings. CMS, 2024. AHA Coding Clinic for ICD-10-CM/PCS. American Hospital Association. AAO Coding Coach — Ophthalmology CPT and ICD-10 Reference 2025. American Academy of Ophthalmology. Bhatt NS, et al. Epiretinal membrane: diagnosis, management, and outcomes. American Academy of Ophthalmology EyeWiki. CMS NCCI Policy Manual FY2025, Chapter 9 — Eye and Ocular Adnexa.