Important Note:
This page is for our commercial plans only for services prior to 1/1/2022.
The diagnoses within these articles are for Dates of Services prior to 2022. For dates of services on and after January 1, 2022, please go to www.eyemedinfocus.com.
When an ophthalmological exam, or an ophthalmological exam and refraction, is performed to diagnose or treat an HMSA member for one of the major conditions listed, the member’s plan benefits for medical services will be applied.
If the service is paid under the member’s medical plan, the service will not be applied to the patient’s maximum benefits for vision services under his or her vision rider.
| ICD-9-CM code | Description |
|---|---|
| 053.21 | Herpes zoster keratoconjunctivitis |
| 054.42 | Herpes simplex dendritic keratitis |
| 054.43 | Herpes simplex disciform keratitis |
| 346.00 - 346.91 | Migraine |
| 360.00 - 360.9 | Disorders of the globe |
| 361.00 - 361.9 | Retinal detachments and defects |
| 362.01 - 362.9 | Other retinal disorders |
| 363.00 - 363.9 | Chorioretinal inflammations, scars and other disorders of choroid |
| 364.00 - 364.9 | Disorders of iris and ciliary body |
| 365.00 - 365.9 | Glaucoma |
| 366.00 - 366.11 | Cataract |
| 366.13 - 366.9 | Cataract |
| 367.51 | Paresis of accommodation (cycloplegia) |
| 367.52 | Total or complete internal ophthalmoplegia |
| 367.53 | Spasm of accommodation |
| 368.00 - 368.03 | Amblyopia ex anopsia |
| 368.2 | Diplopia |
| 368.40 - 368.47 | Visual field defects |
| 368.54 | Achromatopsia |
| 368.61 | Congenital night blindness |
| 368.8 | Other specified visual disturbances (e.g., blurred vision NOS) |
| 370.00 - 370.9 | Keratitis |
| 371.00 - 371.9 | Corneal opacity and other disorders of cornea |
| 372.63 | Symblepharon |
| 372.64 | Scarring of conjunctiva |
| 374.00 - 374.46 | Other disorders of eyelids |
| 374.87 | Dermatochalasis |
| 375.00 - 375.03 | Dacryoadenitis |
| 375.30 - 375.9 | Disorders of lacrimal system |
| 376.00 - 376.9 | Disorders of the orbit |
| 377.00 - 377.9 | Disorders of optic nerve and visual pathways |
| 378.00 - 378.83 | Strabismus and other disorders of binocular eye movements |
| 378.85 - 378.87 | Other disorders of binocular eye movements |
| 378.9 | Unspecified disorder of eye movements |
| 379.00 - 379.59 | Other disorders of eye |
| 379.91 | Pain in or around eye |
| 379.92 | Swelling or mass of eye |
| 784.0 | Headache |
| 918.0 - 918.9 | Superficial injury of eye and adnexa |
| 930.0 | Corneal foreign body |
| ICD-10-CM Code | Description |
|---|---|
| A18.51 - A18.59 | Tuberculous of eye |
| B00.52 | Herpesviral keratitis |
| B02.33 | Zoster keratitis |
| B60.13 | Keratoconjunctivitis due to Acanthamoeba |
| E08.311 - E08.319 | Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy |
| E08.321 - E08.3299 | Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy |
| E08.331 - E08.3399 | Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy |
| E08.341 - E08.3499 | Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy |
| E08.351 - E08.3599 | Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy |
| E08.36 | Diabetes mellitus due to underlying condition with diabetic cataract |
| E08.39 | Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication |
| E09.311 - E09.319 | Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy |
| E09.321 - E09.3299 | Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy |
| E09.331 - E09.3399 | Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy |
| E09.341 - E09.3499 | Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy |
| E09.351 - E09.3599 | Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy |
| E09.36 | Drug or chemical induced diabetes mellitus with diabetic cataract |
| E10.311 - E10.319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy |
| E10.321 - E10.3299 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy |
| E10.331 - E10.3399 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy |
| E10.341 - E10.3499 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy |
| E10.351 - E10.3599 | Type 1 diabetes mellitus with proliferative diabetic retinopathy |
| E10.36 | Type 1 diabetes mellitus with diabetic cataract |
| E11.311 - E11.319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy |
| E11.321 - E11.3299 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy |
| E11.331 - E11.3399 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy |
| E11.341 - E11.3499 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy |
| E11.351 - E11.3599 | Type 2 diabetes mellitus with proliferative diabetic retinopathy |
| E11.36 | Type 2 diabetes mellitus with diabetic cataract |
| E13.311 - E13.319 | Other specified diabetes mellitus with unspecified diabetic retinopathy |
| E13.321 - E13.3299 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy |
| E13.331 - E13.3399 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy |
| E13.341 - E13.3499 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy |
| E13.351 - E13.3599 | Other specified diabetes mellitus with proliferative diabetic retinopathy |
| E13.36 | Other specified diabetes mellitus with diabetic cataract |
| G43.001 - G43.919 | Migraine |
| G44.1 | Vascular headache, not elsewhere classified |
| H02.001 - H02.59 | Other disorders of eyelid |
| H02.831 - H02.839 | Dermatochalasis of eyelid |
| H04.001 - H04.003 | Unspecified dacryoadenitis |
| H04.011 - H04.013 | Acute dacryoadenitis |
| H04.021 - H04.023 | Chronic dacryoadenitis |
| H04.031 - H04.033 | Chronic enlargement of lacrimal gland |
| H04.19 | Other specified disorders of lacrimal gland |
| H04.301 - H04.303 | Unspecified dacryocystitis of lacrimal passage |
| H04.311 - H04.313 | Phlegmonous dacryocystitis of lacrimal passage |
| H04.321 - H04.323 | Acute dacryocystitis of lacrimal passage |
| H04.331 - H04.333 | Acute lacrimal canaliculitis of lacrimal passage |
| H04.411 - H04.413 | Chronic dacryocystitis of lacrimal passage |
| H04.421 - H04.423 | Chronic lacrimal canaliculitis of lacrimal passage |
| H04.431 - H04.433 | Chronic lacrimal mucocele of lacrimal passage |
| H04.511 - H04.513 | Dacryolith of lacrimal passage |
| H04.521 - H04.523 | Eversion of lacrimal punctum |
| H04.531 - H04.533 | Neonatal obstruction of nasolacrimal duct |
| H04.541 - H04.543 | Stenosis of lacrimal canaliculi |
| H04.551 - H04.553 | Acquired stenosis of nasolacrimal duct |
| H04.561 - H04.563 | Stenosis of lacrimal punctum |
| H04.571 - H04.573 | Stenosis of lacrimal sac |
| H04.611 - H04.613 | Lacrimal fistula lacrimal passage |
| H04.69 | Other changes of lacrimal passages |
| H04.811 - H04.813 | Granuloma of lacrimal passage |
| H04.89 | Other disorders of lacrimal system |
| H04.9 | Disorder of lacrimal system, unspecified |
| H05.00 - H05.9 | Disorders of orbit |
| H11.231 - H11.233 | Symblepharon |
| H11.241 - H11.243 | Scarring of conjunctiva |
| H15.001 - H15.9 | Scleritis |
| H16.001 - H16.003 | Unspecified corneal ulcer |
| H16.011 - H16.013 | Central corneal ulcer |
| H16.021 - H16.023 | Ring corneal ulcer |
| H16.031 - H16.033 | Corneal ulcer with hypopyon |
| H16.041 - H16.043 | Marginal corneal ulcer |
| H16.051 - H16.053 | Mooren's corneal ulcer |
| H16.061 - H16.063 | Mycotic corneal ulcer |
| H16.071 - H16.073 | Perforated corneal ulcer |
| H16.101 - H16.103 | Unspecified superficial keratitis |
| H16.111 - H16.113 | Macular keratitis |
| H16.121 - H16.123 | Filamentary keratitis |
| H16.131 - H16.133 | Photokeratitis |
| H16.141 - H16.143 | Punctate keratitis |
| H16.201 - H16.203 | Unspecified keratoconjunctivitis |
| H16.211 - H16.213 | Exposure keratoconjunctivitis |
| H16.221 - H16.223 | Keratoconjunctivitis sicca, not specified as Sjogren's |
| H16.231 - H16.233 | Neurotrophic keratoconjunctivitis |
| H16.241 - H16.243 | Ophthalmia nodosa |
| H16.251 - H16.253 | Phlyctenular keratoconjunctivitis |
| H16.261 - H16.263 | Vernal keratoconjunctivitis, with limbar and corneal involvement |
| H16.291 - H16.293 | Other keratoconjunctivitis |
| H16.301 - H16.303 | Unspecified interstitial keratitis |
| H16.311 - H16.313 | Corneal abscess |
| H16.321 - H16.323 | Diffuse interstitial keratitis |
| H16.331 - H16.335 | Sclerosing keratitis, right eye |
| H16.391 - H16.393 | Other interstitial and deep keratitis, right eye |
| H16.401 - H16.403 | Unspecified corneal neovascularization |
| H16.411 - H16.413 | Ghost vessels (corneal) |
| H16.421 - H16.423 | Pannus (corneal) |
| H16.431 - H16.433 | Localized vascularization of cornea |
| H16.441 - H16.443 | Deep vascularization of cornea |
| H16.8 | Other keratitis |
| H16.9 | Unspecified keratitis |
| H17.01 - H17.9 | Corneal scars and opacities |
| H18.001 - H18.9 | Other disorders of cornea |
| H20.00 - H20.9 | Iridocyclitis |
| H21.00 - H21.9 | Other disorders of iris and ciliary body |
| H22 | Disorders of iris and ciliary body in diseases classified elsewhere |
| H25.011 - H25.013 | Cortical age-related cataract |
| H25.031 - H25.033 | Anterior subcapsular polar age-related cataract |
| H25.041 - H25.043 | Posterior subcapsular polar age-related cataract |
| H25.11 - H25.13 | Age-related nuclear cataract |
| H25.21 - H25.23 | Age-related cataract, morgagnian type |
| H25.811 - H25.813 | Combined forms of age-related cataract |
| H25.89 | Other age-related cataract |
| H25.9 | Unspecified age-related cataract |
| H26.001 - H26.003 | Unspecified infantile and juvenile cataract |
| H26.011 - H26.013 | Infantile and juvenile cortical, lamellar, or zonular cataract |
| H26.031 - H26.033 | Infantile and juvenile nuclear cataract |
| H26.041 H26.043 | Anterior subcapsular polar infantile and juvenile cataract |
| H26.051 - H26.053 | Posterior subcapsular polar infantile and juvenile cataract |
| H26.061 - H26.063 | Combined forms of infantile and juvenile cataract |
| H26.09 | Other infantile and juvenile cataract |
| H26.101 - H26.103 | Unspecified traumatic cataract |
| H26.111 - H26.113 | Localized traumatic opacities |
| H26.121 - H26.123 | Partially resolved traumatic cataract |
| H26.131 - H26.133 | Total traumatic cataract |
| H26.20 | Unspecified complicated cataract |
| H26.211 - H26.213 | Cataract with neovascularization |
| H26.221 - H26.223 | Cataract secondary to ocular disorders (degenerative) (inflammatory) |
| H26.231 - H26.233 | Glaucomatous flecks (subcapsular) |
| H26.31 - H26.33 | Drug-induced cataract |
| H26.40 | Unspecified secondary cataract |
| H26.411 - H26.413 | Soemmering's ring |
| H26.491 - H26.493 | Other secondary cataract |
| H26.8 | Other specified cataract |
| H26.9 | Unspecified cataract |
| H27.01 - H27.9 | Other disorders of lens |
| H28 | Cataract in diseases classified elsewhere |
| H30.001 - H30.93 | Chorioretinal inflammation |
| H31.001 - H31.9 | Other disorders of choroid |
| H32 | Chorioretinal disorders in diseases classified elsewhere |
| H33.001 - H33.8 | Retinal detachments and breaks |
| H34.00 - H34.9 | Retinal vascular occlusions |
| H35.00 - H35.9 | Other retinal disorders |
| H36 | Retinal disorders in diseases classified elsewhere |
| H40.0 - H40.9 | Glaucoma |
| H42 | Glaucoma in diseases classified elsewhere |
| H43.01 - H43.9 | Disorders of vitreous body |
| H44.001 - H44.9 | Disorders of globe |
| H46.01 - H46.9 | Optic neuritis |
| H47.011 - H47.9 | Other disorders of optic (2nd) nerve and visual pathways |
| H49.01 - H49.03 | Third [oculomotor] nerve palsy |
| H49.11 - H49.13 | Fourth [trochlear] nerve palsy |
| H49.21 - H49.23 | Sixth [abducent] nerve palsy |
| H49.31 - H49.33 | Total (external) ophthalmoplegia |
| H49.41 - H49.43 | Progressive external ophthalmoplegia |
| H49.881 - H49.883 | Other paralytic strabismus |
| H49.9 | Unspecified paralytic strabismus |
| H50.00 - H50.9 | Other strabismus |
| H51.0 | Palsy (spasm) of conjugate gaze |
| H51.11 | Convergence insufficiency |
| H51.21 - H51.23 | Internuclear ophthalmoplegia |
| H51.8 | Other specified disorders of binocular movement |
| H51.9 | Unspecified disorder of binocular movement |
| H52.511 - H52.513 | Internal ophthalmoplegia (complete) (total) |
| H52.521 - H52.523 | Paresis of accommodation |
| H52.531 - H52.533 | Spasm of accommodation |
| H53.001 - H53.003 | Unspecified amblyopia |
| H53.011 - H53.013 | Deprivation amblyopia |
| H53.021 - H53.023 | Refractive amblyopia |
| H53.031 - H53.033 | Strabismic amblyopia |
| H53.2 | Diplopia |
| H53.40 | Unspecified visual field defects |
| H53.411 - H53.413 | Scotoma involving central area |
| H53.421 - H53.423 | Scotoma of blind spot area |
| H53.431 - H53.433 | Sector or arcuate defects |
| H53.451 - H53.453 | Other localized visual field defect |
| H53.461 - H53.462 | Homonymous bilateral field defects |
| H53.47 | Heteronymous bilateral field defects |
| H53.481 - H53.483 | Generalized contraction of visual field |
| H53.51 | Achromatopsia |
| H53.63 | Congenital night blindness |
| H53.71 | Glare sensitivity |
| H53.72 | Impaired contrast sensitivity |
| H53.8 | Other visual disturbances |
| H55.00 - H55.89 | Nystagmus and other irregular eye movements |
| H57.00 - H57.9 | Other disorders of eye and adnexa |
| Q15.0 | Congenital glaucoma |
| R51 | Headache |
| S00.201A - S00.279A | Other and unspecified superficial injuries of eyelid and periocular area |
| S05.01xA | Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter |
| S05.02xA | Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter |
| S05.90xA | Unspecified injury of unspecified eye and orbit, initial encounter |
| T15.01xA | Foreign body in cornea, right eye, initial encounter |
| T15.02xA | Foreign body in cornea, left eye, initial encounter |
Other Diagnoses
Listed above are the most common diagnoses related to the eye for which an ophthalmological exam or ophthalmological exam and refraction might be done. However the list is not exhaustive.
For other diagnoses related to the eye, if the diagnosis is not specifically listed on HMSA’s list of Ophthalmological Diagnosis Codes - Minor or Ophthalmological Diagnosis Codes - Refractive the diagnosis will be considered major for purposes of claims payment and the claim will be processed under the member’s medical plan benefits.
Information
For more information, see Ophthalmological Exam - With or Without Refraction.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |