Crystal's MCW Coder Hub🧬 ICD-10-CM H35.372 — Puckering of Macula, Left Eye
Quick Reference
Description
ICD-10 CM H35.372 represents puckering of the macula of the left eye — a condition in which a fibrocellular proliferative membrane (epiretinal membrane, ERM) forms on the inner retinal surface overlying the macula of the left eye. 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 H35.372 when affecting the left eye.
ERM may be idiopathic (most common, occurring in older adults following posterior vitreous detachment) or secondary to an identifiable underlying cause such as retinal detachment repair, laser photocoagulation, cryotherapy, retinal vascular disease, uveitis, or trauma. When secondary, an additional code identifying the underlying condition should be assigned.
Laterality Pair
ICD-10-CM H35.372 is the direct left eye counterpart to H35.371 (right eye). When both eyes are affected at the same encounter, use H35.373 (bilateral) rather than coding H35.371 and H35.372 together. Review laterality at each encounter — a patient may have unilateral disease that progresses to bilateral over time.
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 Selection Guide
Instructional Notes
Excludes2 — Not Included Here, May Co-exist
The following may be coded in addition to H35.372 when both conditions are separately present and documented:
- Macular cyst, hole, or pseudohole, left eye (H35.342) — may coexist with ERM; ERM traction can create a pseudohole appearance; query provider for OCT-confirmed distinction
- Cystoid macular edema (H35.812) — may develop secondary to ERM traction; separately reportable when explicitly documented
- Diabetic macular edema (E11.3212 and related) — diabetic CME may coexist with secondary ERM in diabetic patients; code both when documented
- Pucker following retinal detachment repair — code both H35.372 and the underlying condition
Use Additional Code
When ERM is secondary in etiology, code the underlying or associated condition:
- Post-surgical ERM → H59.812 — Chorioretinal scars after surgery for detachment, left eye
- History of retinal detachment → H33.002 or applicable H33 code
- Post-inflammatory ERM → applicable H30.- uveitis/chorioretinitis code
- Vitreous degeneration / PVD → H43.892 — Vitreous degeneration, left eye (when PVD is separately documented)
- Post-photocoagulation → H59.812 or applicable H59 complication code
Clinical Description
Macular puckering of the left eye results from the same pathophysiologic process as its right eye counterpart — proliferation of fibrous or glial cells on the inner limiting membrane (ILM) of the left macula, most commonly initiated by posterior vitreous detachment (PVD). The resultant epiretinal membrane contracts over time, exerting centripetal tangential traction that distorts the macular architecture of the left eye.
Stages of ERM / macular puckering (left eye):
- Cellophane maculopathy (mild): Thin, transparent, reflective membrane on the left macular surface; may be asymptomatic or cause mild metamorphopsia; increased ILM reflex on fundus exam; OCT shows mild surface irregularity with preserved foveal contour
- Macular pucker (moderate to severe): Thicker contracted membrane; significant macular wrinkling and distortion; pseudohole possible; reduced BCVA left eye; notable metamorphopsia on Amsler grid testing
- Tractional changes: Advanced ERM may produce tractional retinoschisis, subretinal fluid, lamellar hole, or full-thickness macular hole in the left eye
Clinical presentation (left eye):
- Metamorphopsia — distortion of straight lines on Amsler grid; the presenting symptom in the majority of symptomatic cases
- Blurred central vision, left eye — variable; ranges from minimal (cellophane stage) to severe (dense pucker with significant macular thickening)
- Monocular diplopia — from severe macular distortion
- Micropsia — objects appear smaller than actual size
- Reduced contrast sensitivity
- Asymptomatic — discovered incidentally on dilated exam or OCT in early stages, particularly when fellow eye compensates
Diagnostic workup:
- OCT (optical coherence tomography): Gold standard — hyperreflective band on inner retinal surface left eye, macular thickening, loss of foveal contour, intraretinal cysts if present; compare with right eye OCT when bilateral disease is a concern
- Fundus photography: Cellophane sheen and macular wrinkling documented; useful for progression monitoring
- Fluorescein angiography (FA): Not routinely required for ERM diagnosis; useful to evaluate coexisting vascular pathology (e.g., BRVO, CRVO) as secondary etiology
- Amsler grid: Patient self-monitoring tool; particularly important when the right eye has better acuity and the patient may underreport left eye symptoms
Etiology classification:
- Idiopathic ERM — most common; related to PVD of the left eye; no identifiable secondary cause
- Secondary ERM — post-retinal detachment repair (scleral buckle, vitrectomy, pneumatic retinopexy), retinal laser/cryotherapy, uveitis, vascular occlusions (BRVO, CRVO), 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 always be coded to the highest level of specificity supported by documentation.
- When ERM of the left eye is secondary to a prior procedure or condition, the underlying or causative condition should be coded in addition to H35.372.
- Do not assign H35.342 (macular cyst, hole, or pseudohole, left eye) simultaneously with H35.372 without provider confirmation that both are distinctly present — OCT interpretation and provider documentation in the assessment drive code selection.
Sequencing Tips
- Outpatient — First-listed diagnosis: H35.372 when left eye macular pucker/ERM is the primary reason for the encounter
- Secondary diagnosis: When patient presents for a different primary ocular condition and left eye ERM is also documented and monitored, H35.372 is coded additionally
- Bilateral disease discovered at same encounter: Switch to H35.373 — do not code H35.371 + H35.372 simultaneously
- Surgical encounter: H35.372 as first-listed when vitrectomy with left eye membrane peel (67041-LT or 67042-LT) is the primary procedure performed
- POA (inpatient): Almost always Y — macular pucker is chronic/progressive and present before admission in the vast majority of cases
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
H35.372 does not carry HCC weight under CMS-HCC v28. It does not contribute to Medicare Advantage risk scores. However, associated comorbidities that commonly co-exist carry significant HCC weight and must be coded separately when present and documented.
Associated HCC Opportunities — Do Not Miss
While H35.372 has no HCC mapping, the following commonly associated left eye conditions do — code them separately when present:
- Exudative AMD, left eye (H35.3221) — maps to HCC 124
- Proliferative diabetic retinopathy, left eye (E11.3512) — maps to HCC 122
- Nonproliferative diabetic retinopathy, left eye (E11.3412) — maps to HCC 122
- Type 2 diabetes (E11.-) — maps to HCC 37
- These must appear in the provider’s assessment/plan to be coded — imaging report findings alone are insufficient
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 — H35.372 does not function as a CC or MCC
- MCC status: No
- HAC designation: No
- POA exempt: No
- Inpatient note: Inpatient admission solely for left eye macular puckering is rare. Vitrectomy with membrane peel is overwhelmingly performed in the ASC/outpatient setting. When H35.372 appears in the inpatient record, it is typically a secondary diagnosis. DRG is driven by the principal diagnosis and CC/MCC secondary codes.
CPT Crosswalk
| CPT | Description |
|---|---|
| 67041 | Vitrectomy, pars plana; with removal of preretinal cellular membrane (e.g., macular pucker) |
| 67042 | Vitrectomy, pars plana; with removal of internal limiting membrane (e.g., macular hole, macular puckering) |
| 67043 | Vitrectomy, pars plana; with removal of subretinal membrane (e.g., choroidal neovascularization) |
| 67228 | Treatment of extensive or progressive retinopathy, photocoagulation |
| 92134 | Scanning computerized ophthalmic diagnostic imaging, posterior segment (OCT), with interpretation and report |
| 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 — Left Eye
- 67041-LT — Vitrectomy with ERM peel only (preretinal cellular membrane removal); use when ILM is not separately peeled
- 67042-LT — Vitrectomy with ILM peel; use when ILM is peeled (with or without ERM), including combined ERM + ILM cases
- Never bill 67041 and 67042 together for the same eye on the same date — 67042 subsumes 67041 when both membranes are removed; dual billing triggers NCCI edit denial
- Modifier -LT required on all laterality-specific procedures for left eye
ICD-10-PCS Crosswalk
PCS Applicability
ICD-10-PCS applies in the inpatient setting only. Vitrectomy with membrane peel for left eye macular puckering is rarely performed inpatient but is documented here for completeness.
| PCS Code | Root Operation | Body Part | Approach | Device | Qualifier |
|---|---|---|---|---|---|
| 08B34ZZ | Excision | Vitreous, Left | Percutaneous | No Device | No Qualifier |
| 08N34ZZ | Release | Vitreous, Left | Percutaneous | No Device | No Qualifier |
Character breakdown — vitrectomy with ERM peel, left eye (08N34ZZ):
- Section: 0 — Medical and Surgical
- Body System: 8 — Eye
- Root Operation: N — Release (freeing the macula from the constraining epiretinal membrane via tangential traction release)
- Body Part: 34 — Vitreous, Left
- 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 N — Release (releasing macular traction) or B — Excision (removing membrane tissue). Operative note language drives selection — coordinate with coder/provider collaboration. Consistent approach with right eye (08N33ZZ / 08B33ZZ) should be applied per facility coding policy.
ICD-10-CM Crosswalk
| Code | Description | Relationship |
|---|---|---|
| H35.371 | Puckering of macula, right eye | Contralateral equivalent |
| H35.373 | Puckering of macula, bilateral | Use when both eyes affected same encounter |
| H35.379 | Puckering of macula, unspecified eye | Less specific — avoid if laterality documented |
| H35.342 | Macular cyst, hole, or pseudohole, left eye | Related macular pathology — may coexist; Excludes2 |
| H35.352 | Cystoid macular degeneration, left eye | May co-occur — atrophic degeneration |
| H35.362 | Drusen of macula, left eye | May co-occur — AMD-related drusen alongside ERM |
| H35.3221 | Exudative AMD, left eye, with active CNV | Co-occurring condition — code separately; HCC 124 |
| H33.002 | Unspecified retinal detachment, left eye | Common precursor or associated condition |
| H43.892 | Vitreous degeneration, left eye | PVD — common antecedent to idiopathic ERM |
| H59.812 | Chorioretinal scars after surgery for detachment, left eye | Secondary ERM after retinal surgery, left eye |
| H26.412 | Combined forms of age-related cataract, left eye | Frequent comorbidity in ERM surgical candidates |
| E11.3212 | Type 2 diabetes with mild NPDR, left 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 Left Eye Macular Pucker, New Surgical Consultation, Outpatient
Scenario: A 71-year-old patient presents to a retina specialist complaining of worsening metamorphopsia and central blur in the left eye for approximately 8 months. OCT left eye reveals a dense epiretinal membrane with significant macular thickening (central subfield thickness 425 microns) and loss of foveal contour. BCVA left eye 20/100. No identifiable secondary cause documented — attending documents idiopathic ERM left eye. Surgery is recommended. Extended ophthalmoscopy with retinal drawing and OCT performed. First-listed Dx: H35.372 — Puckering of macula, left eye CPT: 92225-LT — Extended ophthalmoscopy, initial; 92134 — OCT posterior segment with interpretation Modifiers: -LT on laterality-specific procedures Notes: Idiopathic ERM — no secondary etiology code required. Document BCVA, metamorphopsia severity, OCT central subfield thickness, and foveal contour status to support surgical medical necessity. If the right eye also has ERM documented at this visit, upgrade to H35.373.
Example 2 — Secondary ERM Left Eye Post-Retinal Detachment Repair, Pre-op Vitrectomy
Scenario: A 63-year-old patient who underwent pars plana vitrectomy for left rhegmatogenous retinal detachment 14 months ago now presents with macular pucker of the left eye. OCT confirms preretinal membrane with macular distortion. Surgeon documents ERM as secondary to prior vitreoretinal surgery. BCVA left eye 20/70. Fundus photography and OCT performed. Vitrectomy with membrane peel planned. First-listed Dx: H35.372 — Puckering of macula, left eye Additional Dx: H59.812 — Chorioretinal scars after surgery for detachment, left eye (secondary etiology) CPT: 92134 — OCT posterior segment; 92250 — Fundus photography Notes: Secondary ERM requires the etiologic condition as an additional code. H59.812 documents post-surgical origin and supports the narrative for medical necessity. Note the prior vitrectomy history in the surgical report — lens status (phakic vs. pseudophakic) should be documented for surgical planning.
Example 3 — Vitrectomy with Combined ERM and ILM Peel, Left Eye, ASC
Scenario: Patient with previously documented left eye macular pucker (H35.372) and BCVA 20/80 undergoes pars plana vitrectomy under monitored anesthesia care in an ASC setting. Operative note documents removal of the epiretinal membrane followed by staining and peeling of the internal limiting membrane (ILM) to reduce recurrence risk. Fellow right eye has early cellophane maculopathy noted on exam but no intervention planned today. First-listed Dx: H35.372 — Puckering of macula, left eye (operative diagnosis) Additional Dx: H35.371 — Puckering of macula, right eye (documented, monitored, no treatment this encounter) CPT: 67042-LT — Vitrectomy with removal of ILM, left eye (subsumes ERM peel — do not also bill 67041) Notes: 67042-LT is the single correct code when both ERM and ILM are removed — 67041 is bundled. Modifier -LT required. The right eye finding (H35.371) is coded as an additional diagnosis since it was examined and documented, even though untreated today. If at a subsequent visit the right eye requires surgery, its own note should reference this bilateral documentation history.
Coding Pitfalls & Tips
Common Errors
- Using H35.379 (unspecified eye) when the left eye is clearly identified in the provider note — always assign H35.372 when laterality is documented
- Billing 67041-LT and 67042-LT together for the same eye on the same date — NCCI edit denial; 67042 subsumes 67041 when both membranes are peeled
- Failing to add the secondary etiology code when ERM is post-surgical or post-inflammatory — incomplete clinical picture, potential medical necessity documentation gap
- Coding both H35.371 and H35.372 at an encounter where bilateral disease is present — use H35.373 instead; the bilateral code is the correct single code for both eyes affected at the same encounter
- Confusing macular pucker (H35.372) with left eye macular hole (H35.342) — OCT is definitive; macular pucker involves a surface membrane causing traction and distortion; macular hole is a full-thickness or partial-thickness defect through the foveal tissue. Surgical approach differs (67042 vs. 67041 typically; provider documentation drives selection)
- Missing fellow eye documentation — if the right eye also has ERM at the same visit, upgrading to H35.373 is required; do not leave unilateral code when bilateral is the accurate clinical picture
Pro Tips
- When monitoring a patient with asymmetric bilateral ERM (one eye surgical, one eye observed), always document both eyes at each visit — code the operative eye as the first-listed and the fellow eye as an additional diagnosis. This establishes a clear progression record in the vault and on the claim.
- The -LT modifier is required for all left eye laterality-specific CPT codes under Medicare and most commercial payers — never omit it on 67041, 67042, 92225, 92226, etc.
- Left eye OCT thickness measurements, BCVA, and Amsler grid findings should be explicitly documented in the provider’s assessment — not just carried over from the imaging report — to satisfy medical necessity documentation requirements for payer review
- For patients with bilateral ERM where the left eye is treated first, update the diagnosis coding at the subsequent right eye encounter — do not carry H35.373 (bilateral) forward after the left eye has been surgically treated and the right eye is the active untreated side
- PVD (H43.892) is frequently the documented antecedent to left eye idiopathic ERM — code separately when documented as a distinct active finding in the provider’s assessment
CDI Query Opportunities
CDI Flags
- Bilateral disease: Is there ERM in both eyes documented on OCT at this encounter? If yes and only one eye is coded, query — H35.373 is the correct bilateral code. Conversely, if H35.373 was coded at a prior visit but one eye has since been treated, confirm current laterality and update accordingly.
- Etiology clarification: Is left eye ERM idiopathic or secondary? History of left eye retinal detachment repair, laser, cryotherapy, uveitis, or vascular occlusion — if present, query the provider to explicitly link the ERM to the prior condition for complete secondary etiology coding
- Coexisting macular pathology: Is there also a pseudohole, lamellar hole, CME, or subretinal fluid in the left eye on OCT? Query provider to distinguish ERM-related pseudohole from a true macular hole (H35.342) — coding and surgical approach differ
- Cystoid macular edema: OCT evidence of intraretinal cysts or subretinal fluid? Query whether H35.812 (left eye CME) is also a separately documented diagnosis
- Associated AMD or diabetic retinopathy: Are drusen (H35.362), wet AMD (H35.3221), or diabetic retinopathy (E11.3412, E11.3512) present in the left eye? These must appear in the provider’s assessment to be coded — confirm they are not documentation-only findings from the imaging report
- PVD documentation: Is posterior vitreous detachment (H43.892) separately documented in the left eye? Code separately when noted as an active finding in the provider note
- Lens status: Is the left eye phakic, pseudophakic (Z96.1), or aphakic? Relevant for surgical complexity documentation and future combined cataract-vitrectomy planning
Related Codes
- Laterality family: H35.371, H35.373, H35.379
- Related left eye macular conditions: H35.342, H35.352, H35.362, H35.812
- AMD crosswalk: H35.3122, H35.3221
- Secondary etiology codes: H59.812, H33.002, H43.892
- Diabetic eye disease: E11.3212, E11.3512
- CPT crosswalk: 67041, 67042, 92134, 92250, 92225, 92226
- PCS crosswalk: 08B34ZZ, 08N34ZZ
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.