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H43.11

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🧬 H43.11: Vitreous hemorrhage, right eye

Diagnosis Type

  • Status: 🟢 Non-HCC

⚠️ Coding Traps

  • Excludes1: Instructional notations for exclusions often apply to the higher-level category or block. For H43.1- (Vitreous hemorrhage):

    • Excludes1 (Pure Excludes - “NOT CODED HERE”):
      • Vitreous hemorrhage with retinal detachment with retinal break (H33.0-).
      • Vitreous hemorrhage with tractional retinal detachment (H33.4-).
      • Traumatic vitreous hemorrhage (Current injury) — these should be coded to the specific injury codes in Chapter 19 (e.g., S05.-).

  • Excludes2 (Not Included Here - “Acceptable to use both”):

    • While not explicitly listed for H43.11, general coding rules for eye disorders suggest that if the hemorrhage is a manifestation of an underlying disease like diabetes, the underlying condition (e.g., E11.331 Type 2 diabetic retinopathy with macular edema) should be coded as well.

  • Use Additional: - If the vitreous hemorrhage is secondary to another condition, such as diabetic retinopathy, you must code the underlying diabetes first.

  • If the hemorrhage is associated with degenerative myopia, there is an instructional note under subcategory H44.2- to use an additional code for the associated vitreous condition.

🧾 Clinical Indicators

(What proves this exists?)

  • Labs:
  • Imaging: - 76512: Ophthalmic Ultrasound, diagnostic; 76512 (Posterior). ◦ Medical Necessity: This code is specifically indicated when the hemorrhage obscures the view of the posterior segment (retina/optic nerve).

    ◦ Coding Tip: Use 76512 for posterior pathology like hemorrhage. Do not use 76513 (Anterior UBM) for this condition

Diagnosis Details

  • Description: Vitreous hemorrhage, right eye [1].
  • HCC Status: No.
    • Note: This code generally does not map to a Hierarchical Condition Category (HCC) for risk adjustment. However, the underlying cause often does (e.g., Proliferative Diabetic Retinopathy E11.351 is HCC 18 or similar). Always code the etiology if known.

Common Associated CPT Codes

  • Imaging:
    • 76512: Ophthalmic Ultrasound, diagnostic; 76512 (Posterior).
      • Usage: Indicated when the hemorrhage obscures the view of the posterior segment [2], [3].
  • Surgical Intervention:
    • 67036: Pars Plana Vitrectomy (PPV).
      • Coverage: Medicare explicitly lists vitreous hemorrhage as a covered indication for vitrectomy [4].
    • 67028: Intravitreal Injection (e.g., Anti-VEGF for neovascularization).

Documentation & Compliance Alerts

  • MIPS / Quality Measures (2025):
    • M1333/M1328: Patients with acute vitreous hemorrhage must be evaluated or re-evaluated within 2 weeks to rule out retinal detachment [5], [6].
  • Bundling (NCCI):
    • Do not bill 76512 (Posterior B-scan) and 76513 (Anterior UBM) on the same eye; they are mutually exclusive. Use 76512 for hemorrhage [2].
    • If performing vitrectomy (67036), the removal of the hemorrhage is included; do not unbundle lens removal (66850) unless the patient is left aphakic [7].

From NotebookLM:

H43.11: Vitreous Hemorrhage, Right Eye

Description

  • Definition: Presence of blood within the vitreous humor of the right eye.
  • Laterality: Specific to the Right Eye.
  • Type: Disorders of vitreous body.

Risk Adjustment (HCC) Status

  • HCC Weight: No.
  • Clinical Note: While H43.11 itself does not carry an HCC weight, the underlying cause often does. You should always code the etiology if known to capture the risk score.

Common Associated CPT Codes

1. Surgical Intervention

  • 67036: Pars Plana Vitrectomy (PPV).
    • Usage: This is the standard code for removing vitreous humor/hemorrhage when no retinal detachment or membrane peeling is required.
    • Coverage: Medicare LCDs explicitly list vitreous hemorrhage as a covered indication for vitrectomy.
  • 67028: Intravitreal Injection.
    • Usage: Often used to inject Anti-VEGF agents (e.g., Avastin, Eylea) if the hemorrhage is caused by neovascularization.

2. Diagnostic Imaging

  • 76512: Ophthalmic Ultrasound, diagnostic; B-scan (Posterior).
    • Medical Necessity: This code is specifically indicated when the hemorrhage obscures the view of the posterior segment (retina/optic nerve).
    • Coding Tip: Use 76512 for posterior pathology like hemorrhage. Do not use 76513 (Anterior UBM) for this condition.

Compliance & Audit Alerts

1. MIPS / Quality Reporting (2025)

  • Measure M1328 / M1333: Patients with a diagnosis of acute vitreous hemorrhage must be evaluated or re-evaluated within 2 weeks to rule out retinal detachment. Failure to document this follow-up interval may result in a quality penalty.

2. NCCI Bundling Rules

  • Ultrasound: You typically cannot bill 76512 (Posterior B-scan) and 76513 (Anterior UBM) on the same eye at the same encounter.
  • Vitrectomy: If performing a vitrectomy (67036) to clear the hemorrhage:
    • Removal of the hemorrhage is included in the code.
    • Lensectomy (66850) is generally bundled and cannot be billed separately unless the patient is left aphakic (no IOL inserted).

Documentation Checklist

  • Laterality: Confirm documentation specifies Right Eye.
  • Etiology: Document the cause (e.g., PDR, retinal tear, trauma) to support medical necessity for procedures.
  • Visual Function: If billing for surgery, document how the hemorrhage impairs daily activities or prevents adequate view for treatment of the retina.

🔗 Related Notes

LIST
FROM "10 Guidelines" OR "20 Specialties"
WHERE contains(file.content, "H43.11")
LIMIT 10

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