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H43.821

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H43.821 — Vitreomacular adhesion, right eye

Short definition

H43.821 identifies vitreomacular adhesion (VMA) of the right eye — a condition in which the posterior vitreous cortex remains abnormally attached to the macula (foveal area of the retina) after partial posterior vitreous detachment, without full-thickness macular hole or clear signs of advanced tractional damage.

Long clinical definition

Vitreomacular adhesion is a vitreoretinal interface disorder characterized by:

  • Partial posterior vitreous detachment in the perifoveal region.
  • Persistent focal attachment of the posterior hyaloid to the macula within roughly 3 mm of the foveal center.
  • Elevation of the cortical vitreous above the retina surrounding the macula, while remaining adherent at the fovea.
  • Absence of significant foveal contour distortion, intraretinal cysts, subretinal fluid, or full-thickness macular hole.

VMA is typically diagnosed on optical coherence tomography (OCT) and may be asymptomatic or associated with mild metamorphopsia, blur, or central visual distortion. It can:

  • Remain stable without progression.
  • Progress to vitreomacular traction (VMT) with foveal distortion and cystic changes.
  • Evolve into a full-thickness macular hole (H35.34x).
  • Spontaneously release, resulting in complete PVD with normalization of the foveal contour.

H43.821 is used when VMA is documented only in the right eye (OD) and there is no indication that the left eye is similarly affected, or when the left eye has a different diagnosis.

Code tree context — H43.82 Vitreomacular adhesion

H43 Disorders of vitreous body

  • H43.8 Vitreous opacities and degeneration
    • H43.80 Unspecified vitreous opacity
    • H43.81 Vitreous degeneration (with laterality child codes)
    • H43.82 Vitreomacular adhesion (non-billable header)
      • H43.821 Vitreomacular adhesion, right eye ← THIS NOTE
      • H43.822 Vitreomacular adhesion, left eye
      • H43.823 Vitreomacular adhesion, bilateral
      • H43.829 Vitreomacular adhesion, unspecified eye
    • H43.89 Other disorders of vitreous body
    • H43.9 Unspecified disorder of vitreous body

Key rule
Do not code H43.82 alone — it is a non-billable header. Always choose a laterality-specific child code such as H43.821 when documentation supports VMA OD.

Includes and excludes

Includes (when right eye only)

Use H43.821 when documentation states:

  • “Vitreomacular adhesion OD” (right eye).
  • “VMA OD on OCT” or “partial PVD with persistent foveal adhesion OD.”
  • Early vitreomacular traction with minimal macular distortion when coder/provider uses “adhesion” terminology and no clear VMT code alternative is defined in practice.
  • Mild vitreoretinal interface disorder OD with OCT evidence of partial vitreous separation but focal foveal attachment and no macular hole.

Common synonymous phrases that map to H43.821 for the right eye:

  • Vitreomacular adhesion OD.
  • Mild vitreomacular traction OD (when documented as adhesion/traction without overt macular changes).
  • Focal vitreofoveal adhesion OD.

Excludes (conceptual and tabular)

From the H43.8 parent:

  • Excludes1 (never coded together for the same eye):

    • Proliferative vitreo-retinopathy with retinal detachment — H33.4x.
      • When abnormal vitreous-retinal interface changes occur with retinal detachment and proliferative membranes, code the detachment complex with H33.4x, not benign adhesion.

  • Excludes2 (may co-exist but typically requires separate coding):

    • Vitreous abscess — H44.02x.
      • Severe infectious pathology involving vitreous; VMA is not the primary issue.

Other conditions to distinguish:

  • Simple posterior vitreous detachment (PVD) — H43.3x (vitreous detachment). Use PVD codes when there is no focal macular adhesion on OCT.
  • Macular hole — H35.34x. When a full-thickness macular hole is present, code the macular hole as primary and VMA as secondary only if specifically documented and clinically relevant.
  • Epiretinal membrane (ERM) — H35.37x. If ERM is present with VMA, code both when documented.

Typical clinical context

Symptoms (right eye)

  • Metamorphopsia (straight lines appear wavy) in OD.
  • Central blur or mild central scotoma OD.
  • Difficulty with reading or fine detail in the right eye only.
  • Sometimes asymptomatic if foveal involvement is minimal.

Exam/OCT findings

  • Partial elevation of posterior hyaloid from perifoveal retina in OD.
  • Persistent focal attachment at the fovea, often seen as a “V-shaped” or “acute-angle” attachment of vitreous to macular surface.
  • Generally preserved foveal contour in pure VMA; if there is distortion, intraretinal cysts, or tractional edema, many clinicians use the term vitreomacular traction (VMT) rather than pure adhesion.
  • Absence of full-thickness macular hole.

Natural history

  • Mild VMA may be observed with periodic OCT monitoring.
  • Some cases spontaneously release, leading to complete PVD and symptom improvement.
  • Others progress to symptomatic VMT or macular hole requiring pharmacologic vitreolysis (ocriplasmin, now rarely used) or surgical vitrectomy.

Relationship to CPT, wRVU, and procedures

H43.821 often appears with:

  • Eye exams

    • 92002 / 92004 — New patient ophthalmologic services.
    • 92012 / 92014 — Established patient exams.
    • 9920x / 9921x — Standard E/M when used instead of 920xx codes.

  • Imaging and diagnostics

    • 92134 — OCT retina (most important: documents VMA, monitors progression).
    • 92201 / 92202 — Extended ophthalmoscopy when peripheral retina is evaluated for tears, traction, or detachment.
    • 92250 — Fundus photography (less specific, but sometimes used to document macular appearance).

  • Surgical interventions (for progression to traction or macular hole; H43.821 may be primary or secondary diagnosis depending on the primary pathology)

    • 67036 — Pars plana vitrectomy.
    • 67041 — PPV with removal of preretinal membrane (ERM); often used when ERM coexists with VMA/VMT.
    • 67042 — PPV with removal of internal limiting membrane (ILM) for macular hole.
    • 67043 — PPV with subretinal membrane removal (less common).

wRVUs

  • H43.821 has no wRVU; wRVUs derive from the above CPT codes.
  • For example:
    • 92134 ~0.35-0.45 wRVU (varies by year).
    • 67036 ~15-17 wRVUs.
    • 67041/67042 often slightly higher than 67036 depending on year.

H43.821 supports medical necessity for OCT monitoring and, if progression occurs, vitrectomy or macular surgery.

HCC / risk adjustment

  • H43.821 does not map to any CMS-HCC.
  • It is not a CC or MCC.
  • Risk impact comes from coexisting macular or systemic diseases:
    • H35.313x — Nonexudative AMD.
    • H35.32x — Exudative AMD.
    • E11.3x1 — Diabetic retinopathy.

Ensure those diagnoses are coded accurately; H43.821 adds structural detail but not risk weight.

MS-DRG considerations

  • In practice, H43.821 is an outpatient retina/ophthalmology diagnosis.
  • In rare inpatient eye admissions (e.g., complex macular surgery with complications), it appears as a non-CC/MCC secondary diagnosis under MDC 02 (eye).
  • It does not materially change DRG assignment unless paired with principal conditions or major procedures that define the DRG.

Coding guidelines and laterality

Laterality

  • Right eye only → H43.821.
  • Left eye only → H43.822.
  • Both eyes → H43.823.
  • Eye not specified → H43.829.

Translate provider documentation:

  • OD → right eye → H43.821.
  • OS → left eye → H43.822.
  • OU → both eyes → H43.823.

When not to use H43.821

  • If documentation indicates only posterior vitreous detachment without macular adhesion, use PVD codes (H43.39x).
  • If a full-thickness macular hole is present and described as the primary problem, the macular hole code (H35.34x) should be primary; VMA may be a secondary diagnosis if documented.
  • If traction is severe with obvious distortion and cystic changes, some practices favor terminology of vitreomacular traction (VMT) and may use a VMT-specific code schema where available; be consistent with local provider preferences.

Common coding scenarios

Example 1 — Asymptomatic VMA OD, observation

Scenario
65-year-old with mild metamorphopsia OD noticed on Amsler grid. OCT shows vitreomacular adhesion OD with normal foveal contour and no cystic changes. Left eye normal.

ICD-10-CM

  • H43.821 — Vitreomacular adhesion, right eye.

CPT

  • 92014 — Comprehensive established eye exam.
  • 92134 — OCT retina, right eye (and OS if imaged).

Example 2 — VMA OD with macular hole

Scenario
70-year-old presents with central vision loss OD. OCT: full-thickness macular hole OD with residual vitreomacular adhesion; OS normal.

ICD-10-CM

  • H35.341 — Macular hole, right eye (primary).
  • H43.821 — Vitreomacular adhesion, right eye (secondary, if documented).

CPT

  • 67042 — Pars plana vitrectomy with ILM peel for macular hole OD.
  • 92134 — OCT retina OD before and after surgery.

Coding note
Macular hole is the primary pathology and should be coded first; VMA is a contributing interface condition.

Example 3 — VMA OD with diabetic macular edema

Scenario
58-year-old with type 2 diabetes, decreased vision OD. OCT: diabetic macular edema OD with vitreomacular adhesion OD; NPDR OU.

ICD-10-CM

  • E11.3211 — Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye.
  • E11.3292 — Type 2 diabetes mellitus with mild NPDR without macular edema, left eye.
  • H43.821 — Vitreomacular adhesion, right eye.

CPT

  • 92014 — Comprehensive exam.
  • 92134 — OCT retina OU.
  • 67028 — Intravitreal injection (anti-VEGF) OD (if performed).

Coding note
The diabetic retinal code drives medical necessity and risk; VMA adds structural context for treatment planning.

Example 4 — VMA OD with ERM

Scenario
72-year-old with metamorphopsia OD. OCT: epiretinal membrane OD with mild vitreomacular adhesion; OS normal.

ICD-10-CM

  • H35.371 — Puckering of macula, right eye (ERM).
  • H43.821 — Vitreomacular adhesion, right eye.

CPT

  • 92014 — Exam.
  • 92134 — OCT retina.
  • 67041 — PPV with ERM peel OD (if surgery performed).

Coding note

ERM (macular pucker) is typically coded as primary; VMA may inform surgical risk and planning.

Example 5 — Bilateral vs. unilateral coding

Scenario
OCT report shows VMA OU, but provider only notes “VMA OD clinically significant; OS minimal and not clinically relevant.” Assessment lists “VMA OD” only.

ICD-10-CM

  • H43.821 — Vitreomacular adhesion, right eye.

Coding note
Code based on final clinical assessment, not raw OCT findings. If the provider chooses to address only OD, code unilateral.

Documentation pearls

  • Always document:

    • Which eye(s) are affected (OD/OS/OU).
    • Whether there is associated ERM, macular edema, macular hole, or diabetic macular disease.
    • OCT findings: degree of adhesion, foveal contour, presence/absence of cystic changes.
    • Symptoms (metamorphopsia, blur, difficulty reading).

  • Clarify whether the condition is:

    • Pure VMA (minimal or no traction).
    • Vitreomacular traction (more significant distortion).
    • Associated with macular hole.

Note

Precise documentation allows coders to select the most accurate ICD-10 combination and supports medical necessity for OCT and potential surgical intervention.

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