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H43.813

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H43.813 — Vitreous degeneration, bilateral

Short definition

H43.813 identifies vitreous degeneration in both eyes, usually age-related liquefaction and structural breakdown of the vitreous gel associated with benign floaters and sometimes chronic post-PVD changes, without acute hemorrhage or retinal detachment.

Long clinical definition

Vitreous degeneration refers to biochemical and structural changes in the vitreous body, including liquefaction (synchysis), aggregation of collagen fibrils, and progressive collapse of the gel away from the retina. In both eyes, this often presents as bilateral floaters with or without a history of posterior vitreous detachment, in the absence of sight-threatening complications such as retinal tears, retinal detachment, or vitreous hemorrhage. H43.813 is used when the provider documents vitreous degeneration or syneresis affecting both eyes (OU).

Code tree context

H43.8 Vitreous opacities and degeneration

  • H43.80 Unspecified vitreous opacity
  • H43.81 Vitreous degeneration (non-billable header)
    • H43.811 Vitreous degeneration, right eye
    • H43.812 Vitreous degeneration, left eye
    • H43.813 Vitreous degeneration, bilateral
    • H43.819 Vitreous degeneration, unspecified eye
  • H43.82 Vitreomacular adhesion (with laterality codes)
  • H43.89 Other disorders of vitreous body
  • H43.9 Unspecified disorder of vitreous body

Use H43.813 when documentation clearly states bilateral vitreous degeneration/syneresis/age-related vitreous changes.

Includes and excludes

Includes (when bilateral)

  • Age-related vitreous degeneration OU
  • Vitreous syneresis OU
  • Benign bilateral vitreous degeneration with floaters and intact retina
  • Chronic bilateral post-PVD vitreous collapse when documented as degeneration rather than active detachment

Excludes (conceptual)

  • Proliferative vitreoretinopathy with retinal detachment (H33.4x series)
  • Vitreous hemorrhage (H43.1x)
  • Vitreous abscess or vitritis (H44.02x or inflammatory codes)
  • Acute posterior vitreous detachment documented as PVD (H43.3x series)

If the provider specifically documents acute PVD or more serious vitreous pathology, code that more specific diagnosis instead of benign degeneration.

Typical use and clinical context

Common outpatient ophthalmology scenarios:

  • Bilateral age-related floaters with benign exam and intact retina OU.
  • Bilateral vitreous syneresis in high myopia with no tears or retinal detachment.
  • Stable post-PVD vitreous degeneration OU when the provider emphasizes chronic degeneration rather than active detachment.
  • Incidental finding of vitreous degeneration OU during routine diabetic eye exam or AMD follow-up.

Symptoms:

  • Floaters (“spots,” “cobwebs,” “threads”) in both eyes, typically chronic and stable.
  • Initial flashes may have occurred at PVD onset, but usually not ongoing once degeneration is chronic.
  • No curtain, no fixed scotoma, and no acute visual field defect suggesting retinal detachment.

Relationship to CPT, wRVU, and billing

H43.813 commonly supports:

  • Eye exam codes:

  • Imaging/procedure codes:

    • 92134 — OCT retina (if evaluating macula or vitreomacular interface)
    • 92201 / 92202 — Extended ophthalmoscopy with drawings (peripheral retinal evaluation to exclude tears/RD)
    • 92250 — Fundus photography (less specific but occasionally used)
    • Rarely 67031 / 67036 — Laser vitreolysis or vitrectomy for symptomatic floaters (only when well-documented as visually significant)

wRVU is attached to these CPT codes; H43.813 serves as a supporting diagnosis demonstrating medical necessity for exams and imaging.

HCC and risk adjustment

  • H43.813 does not map to a CMS-HCC.
  • It does not increase RAF by itself.
  • Document and code coexisting HCC-relevant eye/systemic diagnoses (e.g., E11.3x1 diabetic retinopathy, H35.32x neovascular AMD) separately; H43.813 can remain as a secondary benign diagnosis.

MS-DRG considerations

  • Almost exclusively an outpatient diagnosis.
  • Rarely drives inpatient MS-DRG; when present in inpatient claims, it functions as a non-CC/MCC secondary diagnosis.
  • In the rare case that vitreous surgery is principal inpatient procedure (e.g., vitrectomy for other indications), DRGs 119 or 124-126 may apply based on principal diagnosis and presence of CC/MCC — H43.813 itself does not create CC/MCC status.

Coding guidelines and tips

Laterality

  • Both eyes documented (OU) → H43.813
  • Right eye only → H43.811
  • Left eye only → H43.812
  • Eye not specified → H43.819

Do not use H43.81 alone; it is a non-billable header code.

When not to use H43.813

  • Acute flashes/floaters with documented new PVD → use H43.3x series (vitreous detachment) with laterality.
  • Acute vitreous hemorrhage → use H43.1x.
  • Infectious/inflammatory vitreous pathology → use appropriate H44.x or inflammatory code.
  • If the provider documents only symptoms (“floaters,” “blur”) and does not diagnose vitreous degeneration, consider H53.14 (visual floaters) instead of inferring H43.813.

Symptom vs. structural diagnosis

  • If the provider explicitly documents vitreous degeneration OU as the cause of floaters, H43.813 alone is usually sufficient; H53.14 may be added as secondary when payer policy favors symptom codes.
  • If only symptoms are documented without a structural diagnosis, use the symptom code rather than assuming vitreous degeneration.

Common coding scenarios

Example 1 — Bilateral benign floaters

  • 67-year-old with 3-month history of floaters OU; retina intact OU.
  • Assessment: “Benign age-related vitreous degeneration OU; no retinal tears.”

ICD-10-CM

  • H43.813 — Vitreous degeneration, bilateral

CPT

  • 92014 — Comprehensive eye exam, established patient

Example 2 — Bilateral vitreous degeneration with diabetic retinopathy

  • 58-year-old with type 2 diabetes, mild NPDR OU; benign bilateral vitreous degeneration.

ICD-10-CM

  • E11.3293 — Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
  • H43.813 — Vitreous degeneration, bilateral

CPT

  • 92014 — Comprehensive eye exam
  • 92134 — OCT retina, bilateral

Example 3 — Chronic post-PVD degeneration OU

  • 62-year-old with past documented PVD OU; now stable chronic degeneration and floaters OU; retina intact.
  • Provider documents: “Chronic vitreous degeneration OU, post-PVD.”

ICD-10-CM

  • H43.813 — Vitreous degeneration, bilateral

CPT

  • 92012 — Intermediate eye exam
  • 92202 — Extended ophthalmoscopy (if documented)

Example 4 — Vitreous hemorrhage OD, degeneration OS

  • 70-year-old with acute vitreous hemorrhage OD and benign vitreous degeneration OS.

ICD-10-CM

  • H43.11 — Vitreous hemorrhage, right eye
  • H43.812 — Vitreous degeneration, left eye

Do not code H43.813, as the right eye has a more serious condition than benign degeneration.

Documentation pearls

  • Document fundus findings OU to show retinal tears/detachment were actively ruled out.
  • Note onset and stability of floaters to justify follow-up and imaging.
  • For any surgical intervention for floaters, explicitly document functional impairment and failed conservative management; benign H43.813 alone is not enough to justify vitrectomy for floaters with many payers.
  • Translate OD/OS/OU into laterality-specific ICD-10 codes; avoid non-billable headers.

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