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H59.033

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H59.033 — Cystoid Macular Edema following Cataract Surgery, Bilateral

Code Overview

H59.033 is a billable ICD-10-CM diagnosis code for cystoid macular edema (CME) following cataract surgery, bilateral. It is the bilateral version of the H59.031 (right eye) and H59.032 (left eye) codes, and belongs to the H59.03 subcategory — cystoid macular edema following cataract surgery — within the H59 category for intraoperative and postprocedural complications and disorders of the eye and adnexa, not elsewhere classified.

This condition is also widely known as Irvine-Gass syndrome or pseudophakic cystoid macular edema (PCME). When it affects both eyes following cataract surgery, H59.033 is the single correct code to use — never pair H59.031 + H59.032 simultaneously.

H59.033 is explicitly listed as a covered diagnosis for CPT 92134 (Scanning Computerized Ophthalmic Diagnostic Imaging, posterior segment/OCT) under the CMS SCODI Local Coverage policy, confirming its direct LCD relevance for retina/OCT billing.

Full Code Description

ElementDetail
Full CodeH59.033
DescriptionCystoid macular edema following cataract surgery, bilateral
SynonymsIrvine-Gass syndrome (OU), bilateral PCME, pseudophakic CME (bilateral), bilateral post-cataract CME
BillableYes
ICD-9-CM Approximate Equivalent362.53 — Cystoid macular degeneration (approximate)
Chapter7 — Diseases of the Eye and Adnexa
BlockH55-H59 — Other disorders of eye and adnexa
CategoryH59 — Intraoperative and postprocedural complications and disorders of eye and adnexa, NEC
LateralityBilateral (OU)
7th CharacterNot applicable — 5-character billable code, complete as written
Valid FYFY2025 (Oct 1, 2024 - Sep 30, 2025)
CMS SCODI LCD StatusCovered diagnosis for CPT 92134 per CMS Billing and Coding Article

Clinical Description

Cystoid macular edema (CME) following cataract surgery is a postoperative complication in which inflammatory mediators — primarily prostaglandins, VEGF, cytokines, and other arachidonic acid metabolites — disrupt the blood-retinal barrier. This leads to fluid accumulation in the perifoveal capillary network, creating characteristic cystoid (fluid-filled) spaces in the outer plexiform and inner nuclear layers of the macula. The net effect is macular thickening, photoreceptor disruption, and reduced visual acuity.

When bilateral, CME most commonly arises in the context of:

  • Sequential cataract surgery — both eyes undergo surgery weeks apart and both develop CME in the postoperative period

  • Simultaneous bilateral cataract surgery (ISBCS) — uncommon in the US but increasingly performed; both eyes exposed to surgical inflammation simultaneously

  • High-risk patients — diabetic patients, patients with uveitis, or those on prostaglandin analogs for glaucoma have elevated baseline risk for bilateral post-cataract CME

  • Delayed recognition — CME in the first operative eye may not be recognized until the second eye also develops it, prompting bilateral documentation

Pathophysiology (Bilateral Context)

The fundamental mechanism is identical to unilateral CME: prostaglandin and VEGF-mediated breakdown of the perifoveal blood-retinal barrier. In the bilateral setting, the systemic inflammatory state (e.g., diabetes, uveitic conditions, autoimmune disease) may predispose both eyes equally to developing CME after surgical manipulation. Additionally, a sympathetic or systemic inflammatory response from the first eye’s surgery may lower the threshold for CME development in the fellow eye when it subsequently undergoes surgery.

Clinical Features

  • Onset: Typically 4-12 weeks after cataract surgery in each eye; bilateral presentation may be simultaneous or staggered

  • Symptoms: Painless bilateral blurred or distorted central vision, metamorphopsia, reduced color saturation, micropsia

  • Signs on OCT: Bilateral macular thickening, intraretinal cystic spaces in the outer plexiform and inner nuclear layers, subretinal fluid in severe cases, disorganization of retinal layers

  • FA findings: Classic bilateral petalloid perifoveal leakage pattern; optic disc leakage may also be present

  • Risk factors for bilateral CME: Diabetes mellitus, uveitis, epiretinal membrane, vitreous loss during surgery (in one or both eyes), high preoperative IOP, prostaglandin analog use, prior CME history in either eye

Natural History and Prognosis

Most cases of bilateral post-cataract CME follow the same trajectory as unilateral disease — mild to moderate cases often resolve with conservative topical therapy within 3-4 months. Chronic bilateral CME (persisting > 3 months in one or both eyes) carries a higher risk of permanent central vision loss due to photoreceptor architectural changes. Asymmetric resolution is common — one eye may respond to treatment faster than the other, requiring separate management strategies despite the bilateral code.

Code Structure / Code Tree

H00-H59    Diseases of the Eye and Adnexa
  └── H55-H59    Other disorders of eye and adnexa
        └── H59    Intraoperative and postprocedural complications and disorders of eye and adnexa, NEC
              └── H59.0    Disorders of the eye following [[cataract]] surgery
                    ├── H59.00    Vitreous (touch) syndrome
                    │     ├── [[H59.001]]    ... right eye
                    │     ├── [[H59.002]]    ... left eye
                    │     ├── [[H59.003]]    ... bilateral
                    │     └── [[H59.009]]    ... unspecified eye
                    ├── H59.01    Keratopathy (bullous aphakic) following cataract surgery
                    │     ├── [[H59.011]]    ... right eye
                    │     ├── [[H59.012]]    ... left eye
                    │     ├── [[H59.013]]    ... bilateral
                    │     └── [[H59.019]]    ... unspecified eye
                    ├── H59.02    Cataract (lens) fragments in eye following cataract surgery
                    │     ├── [[H59.021]]    ... right eye
                    │     ├── [[H59.022]]    ... left eye
                    │     ├── [[H59.023]]    ... bilateral
                    │     └── [[H59.029]]    ... unspecified eye
                    ├── H59.03    Cystoid macular edema following cataract surgery    ◄ SUBCATEGORY
                    │     ├── [[H59.031]]    ... right eye
                    │     ├── [[H59.032]]    ... left eye
                    │     ├── H59.033    ... bilateral                                 ◄ THIS CODE
                    │     └── [[H59.039 ]]   ... unspecified eye
                    └── H59.09    Other disorders of the eye following cataract surgery
                          ├── [[H59.091]]    ... right eye
                          ├── [[H59.092]]    ... left eye
                          ├── [[H59.093]]    ... bilateral
                          └── [[H59.099]]    ... unspecified eye

Tip

5-character complete code: H59.033 is billable as a 5-character code. No 7th character extension is required or accepted for this code.

Includes / Excludes Notes

Includes (H59 Category)

  • Cystoid macular edema occurring as an intraoperative or postprocedural complication specific to cataract surgery

  • Irvine-Gass syndrome (bilateral context)

  • Pseudophakic cystoid macular edema (bilateral)

  • Bilateral post-cataract inflammatory macular edema regardless of the time interval between the two cataract procedures

Excludes1 (H59 Category — Do Not Code Together When These Are the Primary Problem)

These conditions are mutually exclusive with H59.033 and should be coded instead when they are the true primary clinical problem:

CodeDescriptionRationale
T85.2Mechanical complication of intraocular lensIf IOL dislocation, malposition, or implant failure is the core issue, use T85.2
T85.3Mechanical complication of other ocular prosthetic devices, implants and graftsDevice-specific mechanical issues
Z96.1PseudophakiaStatus/history code only — not a complication diagnosis
H26.4-Secondary cataracts (posterior capsular opacification, Soemmering’s ring)Distinct post-cataract condition with different management

Excludes2 (H59 — May Be Coded Additionally When Documented)

These conditions are NOT included in H59.033 but may exist alongside it and be coded additionally:

CodeDescriptionCoding Rationale
H35.37-Epiretinal membraneMay coexist with or contribute to bilateral CME; code additionally if documented
H35.30-Degeneration of macula and posterior pole, unspecifiedSeparate posterior segment condition; code additionally if documented
E11.3-Type 2 diabetes with ophthalmic complicationsDiabetes frequently contributes to post-cataract CME; code the diabetic condition when monitored/managed
Z79.899Long-term (current) use of other medicationMay be relevant if prostaglandin analog or other contributing medication is documented

Key Instructional Notes

  • Do not use H59.033 for CME arising from non-cataract surgery etiologies — use the appropriate condition-specific macular edema code (e.g., H35.81 retinal edema, E11.311 diabetic macular edema, H34.8- for vascular occlusion-related edema)

  • H59.033 vs. H59.031 + H59.032: When both eyes are affected, H59.033 is the single correct code. Do not separately code both unilateral codes simultaneously

  • Asymmetric stages or severity between eyes: ICD-10-CM does not currently have a mechanism for coding different severity by eye within H59.033; if asymmetric severity is clinically important, the bilateral code should still be used with detailed narrative documentation in the note

HCC (Hierarchical Condition Category) Mapping

H59.033 does NOT map to a CMS-HCC in standard risk adjustment models.

HCC ModelHCC AssignmentRAF Impact
CMS-HCC Model V28Not assignedNo RAF
RxHCC ModelNot assignedNo RAF
HHS-HCC (ACA Marketplace)Not assignedNo RAF

Clinical documentation note:

While H59.033 carries no direct RAF weight, the underlying conditions that predispose to bilateral CME — particularly diabetes mellitus with ophthalmic complications (E11.3-), which maps to HCC 18 in older models and is flagged in V28 — should always be captured and coded when the provider documents them as monitored or managed during the encounter. Bilateral CME in a diabetic patient without also capturing the diabetes with ophthalmic complications represents an incomplete HCC coding opportunity.

CMS LCD Coverage Note

H59.033 is explicitly listed as a covered diagnosis for:

  • CPT 92134 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), posterior segment, with interpretation and report (OCT retina)

Note

This is documented in the CMS SCODI Billing and Coding Article and means that when H59.033 is on the claim with CPT 92134, the claim meets the covered-diagnosis requirement under this LCD. This is a critical billing note for retina-focused ophthalmology practices using OCT to monitor bilateral CME.

MS-DRG Mapping (Inpatient)

H59.033 as principal diagnosis on an inpatient claim is uncommon. The vast majority of bilateral CME cases are managed entirely outpatient. If coded as PDx:

MS-DRGDescriptionTrigger
124Other Disorders of the Eye with MCCH59.033 as PDx + qualifying MCC
125Other Disorders of the Eye without MCCH59.033 as PDx, no MCC

MDC: MDC 02 — Diseases and Disorders of the Eye

CC/MCC Status:

  • H59.033 is not classified as a CC or MCC in the MS-DRG system

  • Will not independently upgrade DRG assignment when present as a secondary diagnosis

CPT Procedure Codes (Commonly Associated)

Evaluation and Management

CPTDescriptionwRVU (approx.)
92004Comprehensive ophthalmological exam, new patient2.67
92014Comprehensive ophthalmological exam, established patient1.50
92012Intermediate ophthalmological exam, established patient0.97
99214Office visit, established patient, moderate complexity1.92
99213Office visit, established patient, low complexity1.30

Diagnostic Imaging (Covered per CMS LCD)

CPTDescriptionwRVU (approx.)Notes
92134SCODI, posterior segment (OCT retina) — covered dx for H59.033 per CMS SCODI article0.58May be billed bilaterally with -50 modifier or as two separate units per payer policy
92235Fluorescein angiography with interpretation and report1.10Critical for confirming petalloid leakage pattern bilaterally
92240Indocyanine-green (ICG) angiography with interpretation and report1.10Less commonly used for CME; may be added when deep choroidal pathology is also suspected

OCT Bilateral Billing Note:

When OCT (92134) is performed bilaterally, confirm payer policy on whether to bill with modifier -50 (bilateral procedure) or bill each unit separately. CMS typically accepts bilateral reporting for SCODI. Document both eyes explicitly in the interpretation report.

Therapeutic Procedures

CPTDescriptionwRVU (approx.)Assistant Allowed?
67028Intravitreal injection of pharmacologic agent (per eye)~1.60No
67500Retrobulbar injection (periocular corticosteroid, per eye)~0.61No
66821YAG laser capsulotomy (if PCO also present in either eye)~3.44No

Bilateral injection billing note:

If intravitreal injections are performed in both eyes at the same session, bill CPT 67028 twice — once for each eye — with the appropriate laterality modifiers (RT/LT or -E1/-E2/-E3/-E4 per payer) or with modifier -50 if the payer requires bilateral reporting. Do not use one unit to represent bilateral injections.

Specialty Drug Billing (HCPCS) — Common Injectables

HCPCSDrugRouteNotes
J0178Aflibercept (Eylea), 1 mgIntravitrealAnti-VEGF — off-label for CME in some contexts
J2778Ranibizumab (Lucentis), 0.1 mgIntravitrealAnti-VEGF
C9257Bevacizumab (Avastin), compoundedIntravitrealOff-label; check payer coverage
J3300Triamcinolone acetonide, injectable (Kenalog)Intravitreal/periocularSteroid — widely used for CME
J0706Dexamethasone intravitreal implant (Ozurdex), 0.7 mgIntravitrealSustained-release steroid; check Aetna/CMS coverage for H59.033

Ozurdex coverage note

Aetna and some other payers explicitly list H59.03- codes (including H59.033) as covered indications for dexamethasone intravitreal implant (Ozurdex/J0706) when criteria are met. Prior authorization is typically required.

Assistant Surgeon Payable?

ServiceAssistant Allowed?
E/M or ophthalmology examNo
OCT / imaging (92134, 92235)No
Intravitreal injection (67028)No
Periocular injection (67500)No
YAG capsulotomy (66821)No
Pars plana vitrectomy (67041) if escalatedVerify per CPT and payer

Global Period and Modifier Guidance

Post-cataract CME frequently develops during the 90-day global period of the original cataract surgery. The correct modifier depends on whether subsequent treatment was planned or unplanned:

ScenarioModifierKey Principle
Intravitreal injection was pre-planned as a potential post-op therapeutic protocol-58Staged or related procedure; initiates a new global period
Intravitreal injection was unplanned, returning to procedure area for unexpected complication-78Related unplanned return to procedure room; reimbursed at ~80% (intraoperative component only); does NOT initiate a new global period
Treatment by a different/unrelated physician within global period-79Unrelated procedure; rarely applicable for bilateral CME which is clearly related
Treatment occurs after the global period expiresNo modifier neededBill at full fee schedule amount

Note

Bilateral injections in global period: When both eyes require intravitreal injection within the global period of their respective cataract surgeries, apply modifier logic individually for each eye based on whether the injection for that eye was planned or unplanned, and whether it falls within that eye’s cataract surgery global period.

Coding Examples

Example 1 — Sequential Cataract Surgery with Bilateral CME, Conservative Management

Clinical Scenario:
A 71-year-old established patient with Type 2 diabetes underwent cataract surgery OD 8 weeks ago and OS 5 weeks ago. She returns with complaints of decreased central vision and metamorphopsia in both eyes. BCVA is 20/60 OD and 20/70 OS. OCT reveals bilateral CME with central subfield thickness of 430 µm OD and 460 µm OS, with classic cystoid pattern. Fluorescein angiography confirms bilateral petalloid perifoveal leakage. Diagnosis: bilateral pseudophakic cystoid macular edema (Irvine-Gass syndrome). Plan: initiate bromfenac 0.09% BID OU and prednisolone acetate 1% QID OU; follow up in 4 weeks.

ICD-10-CM:

  • H59.033 — Cystoid macular edema following cataract surgery, bilateral

  • E11.36 — Type 2 diabetes mellitus with diabetic cataract (or E11.329 for NPDR without macular edema if retinopathy is documented)

CPT:

  • 92014 — Comprehensive ophthalmological exam, established patient

  • 92134 — SCODI, posterior segment/OCT (bilateral; document both eyes in the report)

  • 92235 — Fluorescein angiography with interpretation

LCD note: H59.033 is a covered diagnosis for 92134 per the CMS SCODI Billing and Coding Article.

Example 2 — Bilateral CME Requiring Bilateral Intravitreal Injections within Global Period (Unplanned)

Clinical Scenario:
A 68-year-old male underwent sequential cataract surgery (OD 10 weeks ago, OS 6 weeks ago). He develops bilateral CME that fails to respond after 6 weeks of topical NSAID and steroid therapy. Both eyes are within their respective 90-day global periods. An unplanned bilateral intravitreal triamcinolone injection is performed.

ICD-10-CM:

  • H59.033 — Cystoid macular edema following cataract surgery, bilateral

CPT:

  • 92014 — Comprehensive ophthalmological exam

  • 92134 — OCT posterior segment (bilateral)

  • 67028-78-RT — Intravitreal injection, modifier -78 (unplanned, related, within global period), right eye

  • 67028-78-LT — Intravitreal injection, modifier -78, left eye

HCPCS:

  • J3300 x2 — Triamcinolone acetonide injectable (one unit per eye injection)

Global period note: Each eye’s injection is within its own cataract surgery global period. Modifier -78 applies to each injection separately. Reimbursement is at ~80% for each. No new global period is initiated with -78.

Example 3 — Bilateral CME with Planned Protocol Injection Series

Clinical Scenario:
A 60-year-old female with a history of uveitis undergoes staged bilateral cataract surgery. Given her high-risk status, the surgeon documents preoperatively that an anti-VEGF injection series will be initiated postoperatively if CME develops. CME is confirmed bilaterally at 6 weeks. The planned first injection of bevacizumab is performed bilaterally.

ICD-10-CM:

  • H59.033 — Cystoid macular edema following cataract surgery, bilateral

  • H20.13 — Chronic iridocyclitis, bilateral (underlying uveitic history)

CPT:

  • 92014 — Comprehensive ophthalmological exam

  • 92134 — OCT posterior segment (bilateral)

  • 67028-58-RT — Intravitreal injection, modifier -58 (staged/planned), right eye — new global period initiated for OD

  • 67028-58-LT — Intravitreal injection, modifier -58 (staged/planned), left eye — new global period initiated for -os

Modifier -58 vs -78: Because the injection series was pre-documented as a planned therapeutic protocol, -58 is correct. This initiates a new 10-day global period for each eye’s injection.

Example 4 — Bilateral CME with Epiretinal Membrane as Contributing Factor

Clinical Scenario:
A 74-year-old patient develops bilateral post-cataract CME. OCT additionally reveals bilateral epiretinal membranes (ERM) that are felt to be contributing to persistent macular edema in both eyes. The retina specialist documents both diagnoses and initiates intravitreal therapy with a plan for possible bilateral pars plana vitrectomy with membrane peel if no improvement.

ICD-10-CM:

  • H59.033 — Cystoid macular edema following cataract surgery, bilateral

  • H35.373 — Epiretinal membrane, bilateral (code also: contributing condition)

CPT (if vitrectomy/membrane peel performed):

  • 67041-50 — Vitrectomy, mechanical, pars plana approach, with removal of preretinal cellular membrane (bilateral, modifier -50); OR bill separately with RT/LT modifiers per payer preference

Bilateral surgery note: Confirm payer policy on bilateral modifier reporting for 67041. Medicare may require two separate line items with RT and LT rather than modifier -50. Always check current payer-specific bilateral rules.

Example 5 — Unilateral Resolution, Updating the Code

Clinical Scenario:
Same patient as Example 1. At the 8-week follow-up, OCT shows complete resolution of CME in the right eye (central subfield thickness normal) but persistent CME in the left eye requiring continued treatment.

ICD-10-CM (updated):

  • H59.032 — Cystoid macular edema following cataract surgery, left eye (change from H59.033 to H59.032 now that the right eye has resolved)

  • Z98.41 — Cataract extraction status, right eye (history of surgery)

Laterality update note:

When bilateral CME resolves in one eye but persists in the other, the coder must update the laterality code accordingly. H59.033 is no longer appropriate when only one eye is actively affected; transition to H59.031 or H59.032 based on which eye remains symptomatic.

Key Coding Pitfalls & Tips

  • Never code H59.031 + H59.032 together for bilateral CME. Use H59.033 as the single code when both eyes are documented as affected. Reporting both unilateral codes simultaneously is incorrect and may cause claim edits.

  • Update laterality when one eye resolves. H59.033 should only be used while both eyes remain actively affected. When one eye resolves, transition to the appropriate unilateral code (H59.031 or H59.032) as documented.

  • Confirm CMS SCODI LCD coverage. H59.033 is explicitly listed as a covered diagnosis for CPT 92134 in the CMS SCODI article — use this to support OCT billing in these patients.

  • Avoid H59.039 (unspecified eye) whenever documentation supports laterality. H59.039 should only be used as a last resort when the provider truly has not specified which eye or eyes are affected.

  • Excludes1 compliance: Do not pair H59.033 with Z96.1 (pseudophakia), T85.2- (IOL mechanical complication), or H26.4- (secondary cataracts) as the primary diagnosis being treated.

  • Bilateral injection billing: Bill each eye as a separate line item with appropriate eye modifiers (-RT/-LT or E-codes) when bilateral intravitreal injections are performed. Do not use one unit to represent both eyes.

  • Global period modifier accuracy: Apply modifier -78 or -58 on a per-eye, per-procedure basis for injections within the global period. Each eye has its own global period clock starting from its individual cataract surgery date.

  • Diabetes coding: In diabetic patients with bilateral CME, always code the relevant diabetes-with-ophthalmic-complication code when the provider addresses it during the encounter. This supports both HCC capture and complete clinical documentation.

CodeDescription
H59.031Cystoid macular edema following cataract surgery, right eye
H59.032Cystoid macular edema following cataract surgery, left eye
H59.039Cystoid macular edema following cataract surgery, unspecified eye — avoid when laterality known
H59.013Keratopathy (bullous aphakic) following cataract surgery, bilateral
H59.023Cataract (lens) fragments in eye following cataract surgery, bilateral
H59.093Other disorders of the eye following cataract surgery, bilateral
H35.373Epiretinal membrane, bilateral
H35.33Drusen (degenerative), bilateral
E11.311Type 2 DM with unspecified diabetic retinopathy with macular edema
H20.13Chronic iridocyclitis, bilateral
Z96.1Pseudophakia — Excludes1 for H59; do not use as the primary complication code
T85.22XADisplacement of intraocular lens, initial encounter — Excludes1
Z98.43Cataract extraction status, bilateral

Last Reviewed: 2026-02-18 | Source: ICD-10-CM FY2025, CMS MPFS, CMS SCODI Billing and Coding Article, AAO Preferred Practice Pattern — Posterior Vitreous, Retina and Vitreous

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