H43.12

Here is a detailed guide note for H43.12, formatted as clean text for your reference.

H43.12: Vitreous Hemorrhage, Left Eye

Description

• Definition: Presence of blood within the vitreous humor of the left eye.
• Laterality: Specific to the Left Eye,.
• Category: Disorders of vitreous body.

Risk Adjustment (HCC) Status

• HCC Weight: No.
• Clinical Note: While H43.12 itself does not map to a Hierarchical Condition Category (HCC), the underlying etiology frequently does. You must code the cause to capture the risk score,.
  • Common HCC Link: Proliferative diabetic retinopathy (e.g., E11.35-) maps to HCC 18 (Diabetes with Chronic Complications).

Common Associated CPT Codes

1. Surgical Intervention

• 67036: Pars Plana Vitrectomy (PPV).
  • Usage: Standard code for removing vitreous hemorrhage when no retinal detachment or membrane peeling is required,.
  • Coverage: Medicare LCDs list vitreous hemorrhage as a covered indication for vitrectomy.
• 67028: Intravitreal Injections Coding.
  • Usage: Used to administer Anti-VEGF agents (e.g., Avastin, Eylea) if the hemorrhage is secondary to neovascularization,.

2. Diagnostic Imaging

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

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 specific follow-up interval may negatively impact quality scores.

2. NCCI Bundling Rules

• Vitrectomy (67036):
  • Removal of the hemorrhage is integral to the procedure.
  • Lensectomy (66850):** Generally bundled. You cannot bill lensectomy separately unless the patient is left aphakic (no IOL is inserted),.
  • Retinal Detachment:** If the hemorrhage is caused by a detachment, do not bill 67036. You must use 67108 (RD repair with vitrectomy) or 67113 (Complex RD repair),.

Documentation Checklist

• Laterality: Confirm the note specifies Left Eye.
• Etiology: Document the cause (e.g., PDR, retinal tear, vein occlusion) to support medical necessity for procedures.
• Visual Function: Document how the hemorrhage impairs daily activities or prevents adequate view for treatment.

Common modifiers (CPT)

Modifier	Meaning (high-level)	Often seen with ophthalmology
-25	Significant, separately identifiable E/M on same day as a procedure	Office visit + same-day minor procedure
-50	Bilateral procedure	Only when the procedure is performed bilaterally
-RT	Right side	Laterality reporting for procedures
-LT	Left side	Laterality reporting for procedures (matches H43.12 laterality)
-59	Distinct procedural service	Separating services when appropriate
-24	Unrelated E/M during postop period	Postop global scenarios
(Modifiers are payer- and CPT/NCCI-context dependent; always follow payer policy and documentation.)​

Common CPTs used with this diagnosis (examples)

Common services considered/used when evaluating or treating vitreous hemorrhage may include:

• 99202-99205 / 99212-99215 (office/outpatient E/M, as appropriate).​

• 92250 (fundus photography) and/or 92201/92202 (extended ophthalmoscopy), when medically necessary and supported.​

• 67040 (vitrectomy; removal of preretinal cellular membrane) or 67036, depending on clinical scenario and documentation.​

Example coding (how it’s used)

Example: Patient presents with sudden floaters and decreased vision; Ophthalmology documents vitreous hemorrhage of the left eye → assign H43.12.​

If the record instead states “vitreous hemorrhage, right eye” or “bilateral,” code to H43.11 or H43.13, respectively