Crystal's MCW Coder Hub🧬 ICD-10-CM H35.61 — Retinal Hemorrhage, Right Eye
Code Classification
ICD-10-CM Diagnosis Code — This is a diagnosis code. Fields for wRVU, assistant payable, and global period are not applicable. For associated inpatient procedure coding, see the ICD-10-PCS Crosswalk section below.
🔍 Code Description
H35.61 classifies retinal hemorrhage of the right eye — bleeding originating from retinal vessels that accumulates within the layers of the retina, between the retina and vitreous (preretinal), or between the retina and retinal pigment epithelium (subretinal), in the right eye.1
Retinal hemorrhage is a finding — not a disease in itself — and represents a clinical manifestation of an underlying vascular, hematologic, traumatic, or inflammatory process affecting the retinal vasculature. The morphology and anatomic layer of the hemorrhage provide critical clues to the etiology: dot and blot hemorrhages arise deep in the inner nuclear and outer plexiform layers from microaneurysm rupture; flame-shaped hemorrhages track along the nerve fiber layer from arterial wall disruption; preretinal (subhyaloid) hemorrhages pool between the retina and vitreous face from neovascular bleeding; and subretinal hemorrhages accumulate beneath the neurosensory retina from choroidal neovascularization.2
The qualifier right eye is captured by laterality character 1. When the etiology is identified — particularly diabetes mellitus — the appropriate combination code from the E08-E13 series replaces H35.61 entirely.
🌳 Code Tree / Hierarchy
H35 Other Retinal Disorders
│
├── H35.0 Background Retinopathy and Retinal Vascular Changes
├── H35.1 Retinopathy of Prematurity
├── H35.2 Other Non-Diabetic Proliferative Retinopathy
├── H35.3 Degeneration of Macula and Posterior Pole
│ ├── H35.31 Nonexudative (dry) age-related macular degeneration
│ └── H35.32 Exudative (wet) age-related macular degeneration
├── H35.4 Peripheral Retinal Degeneration
├── H35.5 Hereditary Retinal Dystrophy
│
├── H35.6 Retinal Hemorrhage ◀ PARENT SUBCATEGORY
│ │ [Excludes2: diabetic retinal disorders — E08-E13 series]
│ │
│ ├── H35.60 Retinal hemorrhage, unspecified eye
│ ├── H35.61 Retinal hemorrhage, right eye ◀ THIS CODE
│ ├── H35.62 Retinal hemorrhage, left eye
│ └── H35.63 Retinal hemorrhage, bilateral
│
├── H35.7 Separation of Retinal Layers
│ ├── H35.71 Central serous chorioretinopathy
│ └── H35.72 Serous detachment of retinal pigment epithelium
└── H35.8 Other Specified Retinal Disorders
├── H35.81 Retinal edema
└── H35.89 Other specified retinal disorders
Do Not Confuse Retinal Hemorrhage with Vitreous Hemorrhage
H35.61 (retinal hemorrhage, right eye) is anatomically and clinically distinct from H43.11 (vitreous hemorrhage, right eye). Retinal hemorrhage occurs within or immediately adjacent to the retinal layers. Vitreous hemorrhage involves blood dispersed into the vitreous cavity itself, typically from neovascular sources (proliferative diabetic retinopathy, retinal tear, CRVO) that bleed into the vitreous gel. A single hemorrhagic event can produce both — for example, a preretinal hemorrhage that breaks through the internal limiting membrane into the vitreous — and in that case, both codes may be assignable if separately documented. Code the hemorrhage type the physician documents; query if the documentation is ambiguous.
✅ Includes
The following clinical terms map to H35.61 and the H35.6 subcategory when occurring in the right eye:1
- Retinal hemorrhage, right eye, NOS
- Dot and blot hemorrhage, right eye (deep inner nuclear/outer plexiform layer)
- Flame-shaped hemorrhage, right eye (superficial nerve fiber layer)
- Preretinal (subhyaloid) hemorrhage, right eye (between retina and vitreous face)
- Subretinal hemorrhage, right eye (between neurosensory retina and RPE)
- Boat-shaped hemorrhage, right eye (gravity-layered preretinal hemorrhage)
All Retinal Hemorrhage Morphologies Map to H35.61
ICD-10-CM does not further subdivide H35.6x by hemorrhage morphology (dot/blot vs. flame vs. preretinal vs. subretinal). All of these clinically distinct presentations are captured at the H35.61 level when the right eye is involved. The morphology distinction is a clinical and documentation detail — important for the treating physician — but does not change the ICD-10-CM code assignment. Document morphology in the CDI query or coding note for clinical completeness, but assign H35.61 for all right-eye retinal hemorrhage presentations.
❌ Excludes
Excludes 2 — Assign Instead of H35.61 When Diabetes Is the Documented Etiology1
| Code Range | Description | Coding Action |
|---|---|---|
| E08.311-E08.359 | Drug/chemical-induced DM with diabetic retinopathy | Use diabetic retinopathy code — NOT H35.61 |
| E09.311-E09.359 | Secondary DM with diabetic retinopathy | Use diabetic retinopathy code — NOT H35.61 |
| E10.311-E10.359 | Type 1 DM with diabetic retinopathy | Use diabetic retinopathy code — NOT H35.61 |
| E11.311-E11.359 | Type 2 DM with diabetic retinopathy | Use diabetic retinopathy code — NOT H35.61 |
| E13.311-E13.359 | Other specified DM with diabetic retinopathy | Use diabetic retinopathy code — NOT H35.61 |
Diabetes + Retinal Hemorrhage — Never H35.61
When a diabetic patient has retinal hemorrhage attributable to their diabetes mellitus, the hemorrhage is captured within the diabetic retinopathy combination code. For example:
- Type 2 DM, mild nonproliferative diabetic retinopathy, right eye, without macular edema → E11.3211
- Type 2 DM, severe nonproliferative diabetic retinopathy, right eye, with macular edema → E11.3451 The hemorrhage morphology and severity is reflected in the nonproliferative vs. proliferative staging, not through a separate H35.61 code. Do NOT assign H35.61 alongside diabetic retinopathy codes for the same eye when diabetes is the etiology.
Exception: If a diabetic patient sustains a retinal hemorrhage from a non-diabetic, separately documented cause (e.g., blunt ocular trauma, anticoagulation-related hemorrhage, retinal macroaneurysm) in the same eye, both the diabetic retinopathy code and H35.61 may be assignable under Excludes 2 logic — but this requires explicit physician documentation distinguishing the two processes.
📋 Clinical Overview
Pathophysiology by Hemorrhage Type
| Hemorrhage Type | Anatomic Location | Mechanism | Classic Etiology |
|---|---|---|---|
| Dot hemorrhage | Inner nuclear layer | Microaneurysm rupture | Diabetic retinopathy, CRVO |
| Blot hemorrhage | Outer plexiform layer | Capillary rupture, intraretinal extravasation | Diabetic retinopathy, BRVO |
| Flame-shaped | Nerve fiber layer | Arteriolar wall disruption, axoplasmic flow disruption | Hypertension, CRVO, papilledema, increased ICP |
| Preretinal (subhyaloid) | Between ILM and vitreous face | Neovascular bleed, Valsalva | PDR, Valsalva retinopathy, Terson syndrome |
| Subretinal | Between neurosensory retina and RPE | Choroidal neovascularization (CNV) | Wet AMD, high myopia, angioid streaks, trauma |
| Boat-shaped | Preretinal, gravity-layered | Blood layers horizontally under gravity | Proliferative DR, Terson, blood dyscrasia |
Etiology
| Etiology | ICD-10-CM | HCC? | Notes |
|---|---|---|---|
| Diabetes mellitus (most common) | E08-E13 diabetic retinopathy codes | ✅ HCC 18 | Do NOT assign H35.61 — use combination code |
| Central retinal vein occlusion (CRVO) | H34.231 Right CRVO | ❌ | Diffuse flame hemorrhages in all four quadrants; H35.61 appropriate alongside |
| Branch retinal vein occlusion (BRVO) | H34.831 Right BRVO | ❌ | Sectoral flame/blot hemorrhages; H35.61 appropriate alongside |
| Hypertensive retinopathy | H35.031 Right eye | ❌ | Flame hemorrhages at disc/posterior pole; assign H35.031 + I10 |
| Wet (exudative) AMD | H35.321x Right eye | ❌ | Subretinal hemorrhage from CNV membrane |
| Trauma | S05.01XA Right eye, initial | ❌ | Commotio retinae, blunt/penetrating injury; external cause code required |
| Blood dyscrasias | D69.6, D61.9, D64.9 | ✅ HCC 46 (some) | Thrombocytopenia, aplastic anemia, leukemia — bilateral flame hemorrhages |
| Anticoagulation | Z79.01 (warfarin) or Z79.899 | ❌ | Document therapeutic agent; supratherapeutic INR if present |
| Valsalva retinopathy | H35.61 | ❌ | Preretinal hemorrhage from sudden IOP increase; vigorous coughing, vomiting, straining |
| Terson syndrome | H35.61 + S06.xx or I60.xx | ✅ (SAH-related) | Retinal/vitreous hemorrhage complicating subarachnoid hemorrhage |
| Retinal macroaneurysm | H35.061 Right eye | ❌ | Arterial macroaneurysm rupture — pre, intra, and subretinal hemorrhage simultaneously |
| Sickle cell retinopathy | D57.x series | ✅ HCC 46 | Peripheral sea-fan neovascularization with vitreous/retinal hemorrhage |
| Non-accidental trauma (NAT) | T74.12XA (child abuse, confirmed) | ❌ | See medicolegal note below — mandatory reporting in most states |
Terson Syndrome — Critical Inpatient Coding Scenario
Terson syndrome describes retinal and/or vitreous hemorrhage occurring as a complication of subarachnoid hemorrhage (SAH), intracerebral hemorrhage, or other sudden intracranial hypertension. The mechanism is rapid transmission of elevated intracranial pressure through the optic nerve sheath, rupturing peripapillary retinal vessels.
In an inpatient admission for SAH with Terson syndrome:
- Principal Diagnosis: I60.xx (subarachnoid hemorrhage by site) — the SAH drives the admission and groups to MDC 01 (Nervous System)
- Additional Diagnosis: H35.61 and/or H43.11 (vitreous hemorrhage, right eye) — the ophthalmic manifestation
- ICD-10-PCS: If pars plana vitrectomy is performed for Terson syndrome, assign the vitrectomy PCS code for the appropriate eye
- This encounter will not group to MDC 02 — the SAH as principal overrides eye MDC assignment
Non-Accidental Trauma and Bilateral Retinal Hemorrhage — Medicolegal Alert
Bilateral retinal hemorrhages in a pediatric patient (particularly an infant or toddler) are a classic finding of abusive head trauma (shaken baby syndrome). When the clinical context supports non-accidental trauma:
- Assign H35.63 (bilateral retinal hemorrhage) — bilateral is the expected presentation
- Assign T74.12XA — Child physical abuse, confirmed, initial encounter (or T76.12XA if suspected)
- Assign perpetrator code Y07.xx — Perpetrator of maltreatment and neglect
- Mandatory reporting to child protective services is a legal requirement in all U.S. states — documentation of the report in the medical record supports coding and compliance
- Do NOT code as accidental trauma if the clinical picture is consistent with NAT and the physician has documented concern for or confirmation of abuse
Documentation Requirements
For accurate, defensible assignment of H35.61, documentation should include:1,2
- Laterality — explicitly right eye
- Morphology — dot/blot, flame, preretinal, subretinal (clinical detail; does not change code but supports specificity)
- Etiology or associated condition — the cause governs code sequencing and additional code assignment
- Acuity and visual impact — relevant for CC/MCC capture and DRG tier
- Active vs. resolving/resolved — ongoing hemorrhage vs. chronic sequelae affects encounter coding
- Associated findings — vitreous involvement, macular edema, retinal detachment — each may be separately codeable
💰 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 |
| RxHCC Assignment | Not Mapped |
H35.61 does not map to an HCC under CMS-HCC v28 and carries no direct RAF weight.3
HCC Capture Lives in the Etiology — Not the Hemorrhage Code
The retinal hemorrhage itself is unweighted, but its underlying cause is often highly significant for risk adjustment:
Underlying Cause HCC RAF Significance Diabetes with diabetic retinopathy HCC 18 High — drives E11.3x coding which replaces H35.61 Sickle cell disease HCC 46 Moderate Aplastic anemia/thrombocytopenia HCC 46 Moderate Proliferative retinopathy (non-diabetic) None direct Low CRVO/BRVO with cardiovascular disease HCC 85/86 (cardiac) Context-dependent In a Medicare Advantage patient with retinal hemorrhage, always trace the etiology to its root systemic condition and ensure all HCC-bearing diagnoses meeting UHDDS criteria are documented and coded.
🏥 MS-DRG Assignment
MDC 02 — Diseases and Disorders of the Eye (when H35.61 is principal)
| 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 |
*Approximate. Verify against IPPS FY2025 Final Rule tables.4
When H35.61 Pulls Out of MDC 02
| Systemic Principal Diagnosis | MDC | DRG Family |
|---|---|---|
| Subarachnoid hemorrhage (I60.xx) — Terson | MDC 01 | Nervous System DRGs 20-22 |
| Thrombocytopenia (D69.6) | MDC 16 | DRGs 811-812 |
| Sickle cell crisis (D57.xx) | MDC 16 | DRGs 811-812 |
| Leukemia with ocular involvement | MDC 16 | Hematology DRGs |
| Uncontrolled hypertension (I10) | MDC 05 | Circulatory DRGs |
CC/MCC Capture — Drive DRG Tier
For admissions where H35.61 is principal (e.g., idiopathic preretinal hemorrhage requiring observation), the DRG tier is entirely determined by the CC/MCC burden of additional diagnoses. MCC examples for an ophthalmology stay: acute respiratory failure, sepsis, HIV disease, acute MI. CC examples: diabetes with complications, hypertension with target organ involvement, moderate-to-severe vision impairment (H54.x). Query the record for all clinically present and documented comorbidities — do not leave uncoded conditions that meet UHDDS criteria.
🔗 Related ICD-10-CM Codes
H35.6x Laterality Family
| Code | Description | Use When |
|---|---|---|
| H35.60 | Retinal hemorrhage, unspecified eye | Laterality truly indeterminate — last resort |
| H35.61 | Retinal hemorrhage, right eye ← This Code | Hemorrhage documented in right eye |
| H35.62 | Retinal hemorrhage, left eye | Hemorrhage documented in left eye |
| H35.63 | Retinal hemorrhage, bilateral | Hemorrhage documented in both eyes |
Retinal Hemorrhage vs. Vitreous Hemorrhage
| Code | Description | Key Distinction |
|---|---|---|
| H35.61 | Retinal hemorrhage, right eye | Blood within retinal layers, preretinal, or subretinal |
| H43.11 | Vitreous hemorrhage, right eye | Blood dispersed into the vitreous cavity — assign additionally if separately documented |
Commonly Associated Etiology Codes
| Code | Description | Relationship |
|---|---|---|
| H34.231 | Central retinal vein occlusion, right eye | CRVO → diffuse 4-quadrant flame hemorrhages |
| H34.8311 | Branch retinal vein occlusion, right eye, with macular edema | BRVO → sectoral hemorrhages |
| H35.031 | Hypertensive retinopathy, right eye | Hypertensive → flame hemorrhages at posterior pole |
| H35.321x | Exudative AMD, right eye (stage-specific) | Wet AMD → subretinal hemorrhage from CNV |
| H35.061 | Retinal vasculitis, right eye | Vasculitis → perivascular flame hemorrhages |
| S05.01XA | Unspecified injury of right eye, initial encounter | Traumatic retinal hemorrhage |
| I60.9 | Subarachnoid hemorrhage, unspecified | Terson syndrome — SAH sequences as principal |
| D69.6 | Thrombocytopenia, unspecified | Blood dyscrasia → bilateral flame hemorrhages |
| Z79.01 | Long-term use of anticoagulants | Anticoagulation-related hemorrhage |
Associated Finding Codes (Code Additionally When Documented)
| Code | Description | Notes |
|---|---|---|
| H43.11 | Vitreous hemorrhage, right eye | If blood also in vitreous cavity |
| H33.001 | Retinal detachment with retinal break, right eye | Subretinal hemorrhage with detachment |
| H35.811 | Retinal edema, right eye | Macular edema accompanying hemorrhage |
| H54.11x | Blindness, right eye, various categories | Vision impairment as CC — code when documented |
🛠️ Commonly Associated CPT Codes (Ophthalmology)
Outpatient and Physician Setting Context
CPT codes are applicable in the outpatient and physician fee schedule settings. In the inpatient setting, ICD-10-PCS procedure codes govern — see PCS Crosswalk below.
| CPT Code | Description | Clinical Application |
|---|---|---|
| 92004 | Ophthalmological exam, comprehensive, new patient | Initial evaluation of acute retinal hemorrhage |
| 92014 | Ophthalmological exam, comprehensive, established patient | Follow-up for known retinal hemorrhage |
| 92250 | Fundus photography with interpretation and report | Documents hemorrhage location, extent, morphology, and progression |
| 92235 | Fluorescein angiography with interpretation and report | Identifies source vessel, CNV membrane, ischemic areas; determines treatability |
| 92134 | OCT posterior segment | Retinal thickness, subretinal fluid, macular hemorrhage extent; H35.61 is covered on CMS OCT LCD |
| 92240 | ICG angiography | Choroidal hemorrhage assessment; evaluates CNV not visible on FA |
| 67210 | Photocoagulation treatment, macular and retinal lesion | Focal laser to seal leaking macroaneurysm or feeder vessel |
| 67028-RT | Intravitreal injection, right eye | Anti-VEGF (bevacizumab, ranibizumab, aflibercept) for CNV-related subretinal hemorrhage; corticosteroid for macular edema |
| 67036 | Vitrectomy, mechanical, pars plana approach | Dense preretinal or vitreous hemorrhage obscuring vision — see NCCI bundling note |
| 67041 | Vitrectomy with focal endolaser | PPV + endolaser for proliferative source of hemorrhage |
| 67228 | Treatment of extensive or progressive retinopathy, photocoagulation | Pan-retinal photocoagulation (PRP) for neovascular hemorrhage source |
NCCI Bundling — Key Surgical Pairs
67036 (Vitrectomy) Bundles Extensively
When 67036 (pars plana vitrectomy) is performed, most associated retinal procedures in the same session — including 67210 (focal photocoagulation), 67228 (PRP), and 67028 (intravitreal injection) — may be bundled per NCCI. Review current NCCI PTP edit tables before billing combinations. Endolaser performed during vitrectomy is typically captured by 67041 (vitrectomy with focal endolaser) or 67042 (with panretinal photocoagulation) rather than billing 67036 + 67228 separately. Always verify NCCI column 1/column 2 edits for the specific code pair and fiscal year.
🔬 ICD-10-PCS Crosswalk (Inpatient Procedures)
When H35.61 is an inpatient diagnosis and a procedure is performed, the following ICD-10-PCS sections are applicable. All seven characters must be completed using the FY2025 PCS tables.5
| PCS Section | Body System | Root Operation | Clinical Application |
|---|---|---|---|
| 0 (Medical & Surgical) | 8 (Eye) | 5 (Destruction) | Laser photocoagulation of bleeding retinal vessel, macroaneurysm, or neovascular source — Body Part: Retina Right = J; Approach: 3 (Percutaneous via contact lens delivery); Device: Z; Qualifier: Z |
| 0 (Medical & Surgical) | 8 (Eye) | B (Excision) | Pars plana vitrectomy (PPV) for dense preretinal or vitreous hemorrhage — Body Part: Vitreous Right = 5; Approach: 3 (Percutaneous); Device: Z; Qualifier: Z |
| 3 (Administration) | E (Physiological Systems & Anatomical Regions) | 0 (Introduction) | Intravitreal injection of anti-VEGF or corticosteroid — Body Part: C (Eye); Approach: 3 (Percutaneous); Substance: specify anti-neoplastic, anti-infective, or other therapeutic; Device: Z |
Vitrectomy Root Operation — Excision, Not Extraction
In ICD-10-PCS, pars plana vitrectomy for hemorrhage is coded as root operation B (Excision) — cutting out/off a portion of the vitreous body. It is NOT coded as Extraction (D) or Drainage (9). Extraction involves pulling force without cutting; Drainage involves withdrawing fluid. Vitrectomy uses mechanical cutting instruments (vitrector) to excise vitreous tissue along with the contained hemorrhage — Excision is the correct root operation.
If an air-fluid exchange or gas tamponade is also performed during PPV, an additional ICD-10-PCS code for Introduction (3E0C) of the tamponade substance (gas or silicone oil) into the eye may be assigned — document substance type clearly to support PCS device/qualifier selection.
💊 Coding Scenarios and Examples
Scenario 1 — Idiopathic Preretinal Hemorrhage, Right Eye (Outpatient)
Clinical Vignette: A 34-year-old healthy female presents with sudden blurring of vision in the right eye after a vigorous episode of vomiting. Examination reveals a boat-shaped preretinal (subhyaloid) hemorrhage in the right eye adjacent to the macula. No retinal tears, neovascularization, or systemic disease documented. Fundus photography and OCT performed. Impression: Valsalva retinopathy, right eye — preretinal hemorrhage.
CPT Codes:
- 92014 — Comprehensive ophthalmological exam, established patient
- 92250 — Fundus photography with interpretation (documents hemorrhage extent and morphology)
- 92134 — OCT posterior segment (macular involvement assessment)
ICD-10-CM:
- H35.61 — Retinal hemorrhage, right eye (preretinal/Valsalva — no systemic etiology; H35.61 appropriate)
Valsalva Retinopathy — No Additional Etiology Code Needed
Valsalva retinopathy results from a sudden rise in intrathoracic pressure transmitted to the retinal veins. When the cause is a one-time Valsalva event (vomiting, coughing, straining) without underlying systemic disease, H35.61 stands alone. There is no specific ICD-10-CM code for Valsalva retinopathy — it maps to H35.61 via the preretinal hemorrhage inclusion. Most cases resolve spontaneously within weeks to months with observation only.
Scenario 2 — CRVO with Retinal Hemorrhage, Right Eye (Outpatient/Inpatient)
Clinical Vignette: A 67-year-old male with hypertension presents with sudden, painless loss of vision in the right eye. Fundus exam reveals diffuse, flame-shaped hemorrhages in all four quadrants, disc edema, and dilated tortuous veins — classic “blood and thunder” fundus. Fluorescein angiography confirms right central retinal vein occlusion with associated diffuse retinal hemorrhage and macular edema, right eye.
ICD-10-CM Diagnosis Codes:
- H34.231 — Central retinal vein occlusion, right eye (principal ophthalmic diagnosis)
- H35.61 — Retinal hemorrhage, right eye (the hemorrhage is a distinct, separately documented finding of the CRVO — code additionally)
- H35.811 — Retinal edema, right eye (separately documented macular edema)
- I10 — Essential (primary) hypertension (documented comorbidity — UHDDS criteria met)
Coding Both CRVO and H35.61
When CRVO (H34.231) is the cause of the retinal hemorrhage, the hemorrhage is expected — but it is separately codeable because it is a distinct, documented clinical finding with its own clinical significance and treatment implications. Unlike the diabetic retinopathy combination codes that explicitly capture hemorrhage within the code itself, CRVO codes do not encode the retinal hemorrhage. Assign both.
Scenario 3 — Terson Syndrome (Inpatient Neurosurgery/ICU)
Clinical Vignette: A 55-year-old female is admitted via the ED following sudden-onset worst-headache-of-life. CT confirms subarachnoid hemorrhage (SAH) from a ruptured right MCA aneurysm. Ophthalmology is consulted on hospital day 2. Dilated fundus exam reveals bilateral preretinal hemorrhages at the disc and posterior pole — consistent with Terson syndrome. Right eye hemorrhage is denser than left.
Principal Diagnosis:
- I60.12 — Nontraumatic subarachnoid hemorrhage from right middle cerebral artery (drives the admission — MDC 01)
Additional Diagnoses:
- H35.63 — Retinal hemorrhage, bilateral (Terson syndrome — both eyes involved; bilateral code preferred over separate right and left)
- H43.13 — Vitreous hemorrhage, bilateral (if blood is also documented in vitreous cavity)
MS-DRG Assignment:
- Groups to MDC 01 (Nervous System) — NOT MDC 02 — because I60.12 is principal
- DRG 020 (Intracranial Vascular Procedures w/ PDx Hemorrhage w/ MCC) or similar per DRG grouper — vastly higher relative weight than MDC 02 DRGs
Terson Syndrome — H35.61 or H35.63?
If the hemorrhage is clearly bilateral on fundoscopic exam, assign H35.63 (bilateral) rather than separate right and left codes. If only the right eye is documented as having retinal hemorrhage on the formal ophthalmic examination, assign H35.61. Do not assume bilateral involvement in Terson syndrome without explicit documentation — it is bilateral in approximately 70-80% of cases clinically, but coding requires documentation, not assumption.
Scenario 4 — Non-Accidental Trauma, Bilateral Retinal Hemorrhage (Pediatric Inpatient)
Clinical Vignette: A 7-month-old infant is brought to the ED by parents reporting “the baby fell off the couch.” CT head reveals bilateral subdural hematomas. Ophthalmology consultation documents bilateral, diffuse, multilayered retinal hemorrhages extending to the periphery — highly characteristic of abusive head trauma. Child Protective Services notified. Admission for neurosurgical management.
Principal Diagnosis:
- S09.90XA — Unspecified injury of head, initial encounter (or the specific intracranial injury code)
Additional Diagnoses:
- H35.63 — Retinal hemorrhage, bilateral (the ophthalmic finding)
- T74.12XA — Child physical abuse, confirmed, initial encounter (mandatory when abuse is confirmed by the physician)
- Y07.9 — Unspecified perpetrator of maltreatment and neglect (when perpetrator is unknown or unspecified)
Mandatory Reporting — Do Not Code as Accidental
Bilateral multilayered retinal hemorrhages extending to the periphery in an infant, combined with subdural hematoma and an inconsistent mechanism of injury, are pathognomonic for abusive head trauma (AHT). Never code this as an accidental fall if the physician’s documentation indicates concern for or confirmation of non-accidental trauma. Medical coders have an obligation to accurately reflect the physician’s clinical impression. Use T74.12XA (confirmed) or T76.12XA (suspected) based on physician documentation. The choice between confirmed and suspected has significant legal and DRG implications.
Scenario 5 — Subretinal Hemorrhage from Wet AMD, Right Eye (Outpatient)
Clinical Vignette: An 81-year-old female with known bilateral wet AMD presents with acute decrease in central vision, right eye. Examination reveals a large subretinal hemorrhage under the macula, right eye. OCT confirms subretinal fluid and hemorrhage from choroidal neovascularization (CNV). Fluorescein angiography confirms active CNV membrane. Intravitreal bevacizumab injection, right eye, administered.
CPT Codes:
- 92014 — Comprehensive ophthalmological exam, established patient (modifier -25 required — significant E/M separate from injection)
- 92134 — OCT posterior segment
- 92235 — Fluorescein angiography (confirms CNV activity)
- 67028-RT — Intravitreal injection, right eye (bevacizumab)
ICD-10-CM:
- H35.3213 — Exudative AMD, right eye, with active choroidal neovascularization (principal ophthalmic diagnosis; stage-specific AMD code)
- H35.61 — Retinal hemorrhage, right eye (subretinal hemorrhage is a distinct documented finding — separately codeable)
Wet AMD + Subretinal Hemorrhage — Code Both
The exudative AMD code (H35.32xx) does not inherently capture the subretinal hemorrhage as a component. The hemorrhage is separately documented and clinically distinct — assign H35.61 additionally. This is analogous to the CRVO scenario: the primary condition drives the encounter, and the hemorrhage adds clinical detail that supports medical necessity and encounter complexity.
⚠️ Coding Pitfalls and Tips
| Pitfall or Tip | |
|---|---|
| ❌ | Never assign H35.61 when diabetes is the documented etiology — use E11.3x (or type-equivalent) per Excludes 2 instruction; this is the most common error with H35.6x codes |
| ❌ | Do not confuse H35.61 (retinal hemorrhage) with H43.11 (vitreous hemorrhage) — anatomically distinct; both may be present simultaneously and codeable if separately documented |
| ❌ | Do not default to H35.60 (unspecified eye) when laterality is documented — always assign the laterality-specific code |
| ❌ | Do not code traumatic retinal hemorrhage as accidental if the physician documents concern for or confirmation of non-accidental trauma (NAT) — medicolegal and compliance implications |
| ❌ | Do not assume bilateral in Terson syndrome without explicit bilateral documentation — approximately 70-80% are bilateral clinically, but coding requires documented laterality |
| ✅ | Code the etiology alongside H35.61 — CRVO, BRVO, wet AMD, trauma, blood dyscrasia; the hemorrhage code alone does not communicate the clinical story |
| ✅ | In Terson syndrome, sequence SAH as principal — the encounter will group to MDC 01, not MDC 02; significantly higher DRG weight |
| ✅ | Query for hemorrhage morphology (preretinal vs. subretinal vs. intraretinal) in complex cases — while it does not change the ICD-10-CM code, it supports clinical documentation integrity and may prompt additional associated code assignments |
| ✅ | Capture vision impairment codes (H54.xx) as additional diagnoses when documented — they frequently qualify as CCs and drive DRG 125 vs. 126 |
| ✅ | In pediatric patients with bilateral retinal hemorrhages, always review for NAT indicators and assign T74.12XA or T76.12XA as appropriate when the physician documents abuse concerns |
| ✅ | Code anticoagulation status (Z79.01) when retinal hemorrhage occurs in a patient on warfarin, heparin, or DOACs — documents clinical context and supports medical necessity |
📚 Sources
1. CMS/NCHS. ICD-10-CM Official Guidelines for Coding and Reporting, FY2025; Tabular List — H35.6 Retinal Hemorrhage subcategory; H35 Excludes 2 notation for diabetic retinal disorders; General Guidelines Section I.B — Laterality; Section I.C.19 — Injuries, external cause coding, and non-accidental trauma.
2. Bhavsar AR, Bhavsar SG. “Retinal Hemorrhage.” In: Yanoff M, Duker JS. Ophthalmology, 5th ed. Elsevier; 2019. Chapters on Retinal Vascular Disease and Vitreous Hemorrhage.
3. CMS. 2024 Medicare Advantage Risk Adjustment — CMS-HCC Model v28 ICD-10-CM Mappings. Baltimore, MD: Centers for Medicare & Medicaid Services.
4. CMS. IPPS Final Rule FY2025 — MS-DRG Definitions Manual v42. MDC 02 DRGs 124-126; MDC 01 (Nervous System) — Terson syndrome DRG context.
5. CMS. ICD-10-PCS Reference Manual FY2025; Section 0 Body System 8 (Eye), Root Operations B (Excision) and 5 (Destruction); Section 3 (Administration), Body System E, Root Operation 0 (Introduction). Vitrectomy root operation classification.
6. AMA. CPT Professional Edition 2025. Ophthalmology subsection (92002-92499); Surgery/Eye and Ocular Adnexa — vitrectomy codes 67036-67042; retinal photocoagulation 67210, 67228.
7. CMS. NCCI Policy Manual for Medicare Services, v31.0; Chapter 7 — Eye and Ocular Adnexa; vitrectomy bundling principles for 67036.
8. Michalewska Z, Nawrocki J. “Terson Syndrome.” Ophthalmologica. 2010;224(3):141-145. Clinical review of bilateral retinal hemorrhage in subarachnoid hemorrhage.
9. American Academy of Ophthalmology. Policy Statement: Ophthalmologist’s Role in Detecting and Reporting Child Abuse. AAO; 2022. Non-accidental trauma and retinal hemorrhage documentation guidelines.