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Electroretinography

Section: Diagnostic Medical
Effective Date: September 01, 2019
Revised Date: August 02, 2019
Last Reviewed: July 16, 2019

Description

The full field electroretinogram (ERG) is used to detect loss of retinal function or distinguish between retinal and optic nerve lesions. ERG measures the electrical activity generated by neural and non-neuronal cells in the retina in response to a light stimulus.

The focal or foveal ERG (fERG) is useful in providing information regarding diseases limited to the macula.

Multi-focal electroretinography (mfERG) is a higher resolution form of ERG, enabling assessment of ERG activity in small areas of the retina.

Pattern ERG (PERG) uses pattern-reversal stimuli and is used to detect subtle optic neuropathies.

Criteria

Electroretinography used to diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions may be considered medically necessary for ANY ONE of the following indications (This is not an all-inclusive list):

  • Toxic retinopathies, including those caused by intraocular metallic foreign bodies, Vigabatrin and Chlorpromazine; or
  • Diabetic retinopathy; or
  • Retinal vascular disease (e.g., Central Retinal Artery Occlusion [CRAO], Transient Retinal Artery Occlusion, Central Retinal Vein Occlusion [CRVO], Branch Vein Occlusion [BVO], and sickle cell retinopathy); or
  • Autoimmune retinopathies (e.g., Cancer Associated Retinopathy [CAR], Melanoma Associated Retinopathy [MAR], and Acute Zonal Occult Outer Retinopathy [AZOOR]); or
  • Retinal detachment; or
  • Assessment of retinal function after trauma (e.g., vitreous hemorrhage, dense cataracts, macula scars and other conditions where the fundus cannot be visualized); or
  • Retinitis pigmentosa and related hereditary degenerations; or
  • Retinitis punctata albescens; or
  • Leber’s congenital amaurosis; or
  • Choroideremia; or
  • Gyrate atrophy of the retina and choroid; or
  • Goldman-Favre syndrome; or
  • Congenital stationary night blindness; or
  • X-linked juvenile retinoschisis; or
  • Achromatopsia; or
  • Cone dystrophy; or
  • Disorders mimicking retinitis pigmentosa; or
  • Usher Syndrome; or
  • Retinal Dystrophies (e.g., Stargardt’s disease, Fundus Flavimaculata, North Carolina macular dystrophy, Best’s Vitelliform dystrophy, Sorsby’s macular dystrophy).

All other indications for electroretinography not listed above, except glaucoma are considered not medically necessary.

Procedure Codes

0509T 
92273 92274

mfERG may be considered medically necessary to detect chloroquine (Aralen) and hydroxychloroquine (Plaquenil) toxicity.

Procedure Codes

92274

ERG (all forms: ERG, fERG, mfERG, PERG, etc.) for glaucoma is considered experimental/investigational and therefore non-covered, due to lack of scientific based evidence available in the current published peer reviewed literature.

Procedure Codes

0509T
92273 92274

Covered Diagnosis Codes for Procedure Codes 0509T, 92273 and 92274

A18.53D18.09E08.311E08.319E08.3211E08.3212E08.3213
E08.3291E08.3292E08.3293E08.3311E08.3312E08.3313E08.3391
E08.3392E08.3393E08.3411E08.3412E08.3413E08.3491E08.3492
E08.3493E08.3511E08.3512E08.3513E08.3521E08.3522E08.3523
E08.3531E08.3532E08.3533E08.3541E08.3542E08.3543E08.3551
E08.3552E08.3553E08.3591E08.3592E08.3593E09.311E09.319
E09.3211E09.3212E09.3213E09.3291E09.3292E09.3293E09.3311
E09.3312E09.3313E09.3391E09.3392E09.3393E09.3411E09.3412
E09.3413E09.3491E09.3492E09.3493E09.3511E09.3512E09.3513
E09.3521E09.3522E09.3523E09.3531E09.3532E09.3533E09.3541
E09.3542E09.3543E09.3551E09.3552E09.3553E09.3591E09.3592
E09.3593E10.311E10.319E10.3211E10.3212E10.3213E10.3291
E10.3292E10.3293E10.3311E10.3312E10.3313E10.3391E10.3392
E10.3393E10.3411E10.3412E10.3413E10.3491E10.3492E10.3493
E10.3511E10.3512E10.3513E10.3521E10.3522E10.3523E10.3531
E10.3532E10.3533E10.3541E10.3542E10.3543E10.3551E10.3552
E10.3553E10.3591E10.3592E10.3593E11.311E11.319E11.3211
E11.3212E11.3213E11.3291E11.3292E11.3293E11.3311E11.3312
E11.3313E11.3391E11.3392E11.3393E11.3411E11.3412E11.3413
E11.3491E11.3492E11.3493E11.3511E11.3512E11.3513E11.3521
E11.3522E11.3523E11.3531E11.3532E11.3533E11.3541E11.3542
E11.3543E11.3551E11.3552E11.3553E11.3591E11.3592E11.3593
E13.311E13.319E13.3211E13.3212E13.3213E13.3291E13.3292
E13.3293E13.3311E13.3312E13.3313E13.3391E13.3392E13.3393
E13.3411E13.3412E13.3413E13.3491E13.3492E13.3493E13.3511
E13.3512E13.3513E13.3521E13.3522E13.3523E13.3531E13.3532
E13.3533E13.3541E13.3542E13.3543E13.3551E13.3552E13.3553
E13.3591E13.3592E13.3593E50.5E50.9F44.6G45.3
H15.031H15.032H15.033H20.011H20.012H20.013H30.001
H30.002H30.003H30.011H30.012H30.013H30.021H30.022
H30.023H30.031H30.032H30.033H30.041H30.042H30.043
H30.101H30.102H30.103H30.111H30.112H30.113H30.121
H30.122H30.123H30.131H30.132H30.133H30.141H30.142
H30.143H30.21H30.22H30.23H30.811H30.812H30.813
H30.891H30.892H30.893H30.91H30.92H30.93H31.001
H31.002H31.003H31.011H31.012H31.013H31.021H31.022
H31.023H31.091H31.092H31.093H31.101H31.102H31.103
H31.111H31.112H31.113H31.121H31.122H31.123H31.20
H31.21H31.22H31.23H31.29H31.301H31.302H31.303
H31.311H31.312H31.313H31.321H31.322H31.323H31.401
H31.402H31.403H31.411H31.412H31.413H31.421H31.422
H31.423H33.001H33.002H33.003H33.011H33.012H33.013
H33.021H33.022H33.023H33.031H33.032H33.033H33.041
H33.042H33.043H33.051H33.052H33.053H33.101H33.102
H33.103H33.111H33.112H33.113H33.191H33.192H33.193
H33.21H33.22H33.23H33.301H33.302H33.303H33.311
H33.312H33.313H33.321H33.322H33.323H33.331H33.332
H33.333H33.41H33.42H33.43H33.8H34.01H34.02
H34.03H34.11H34.12H34.13H34.211H34.212H34.213
H34.231H34.232H34.233H34.8110H34.8111H34.8112H34.8120
H34.8121H34.8122H34.8130H34.8131H34.8132H34.821H34.822
H34.823H34.8310H34.8311H34.8312H34.8320H34.8321H34.8322
H34.8330H34.8331H34.8332H34.9H35.00H35.012H35.013
H35.021H35.022H35.023H35.031H35.032H35.033H35.041
H35.042H35.043H35.051H35.052H35.053H35.061H35.062
H35.063H35.071H35.072H35.073H35.09H35.101H35.102
H35.103H35.111H35.112H35.113H35.121H35.122H35.123
H35.131H35.132H35.133H35.141H35.142H35.143H35.151
H35.152H35.153H35.161H35.162H35.163H35.171H35.172
H35.173H35.21H35.22H35.23H35.30H35.311H35.3110
H35.3111H35.3112H35.3113H35.3114H35.3120H35.3121H35.3122
H35.3123H35.3124H35.3130H35.3131H35.3132H35.3133H35.3134
H35.3210H35.3211H35.3212H35.3213H35.3220H35.3221H35.3222
H35.3223H35.3230H35.3231H35.3232H35.3233H35.33H35.341
H35.342H35.343H35.351H35.352H35.353H35.361H35.362
H35.363H35.371H35.372H35.373H35.381H35.382H35.383
H35.40H35.411H35.412H35.413H35.421H35.422H35.423
H35.431H35.432H35.433H35.441H35.442H35.443H35.451
H35.452H35.453H35.461H35.462H35.463H35.50H35.51
H35.52H35.53H35.54H35.61H35.62H35.63H35.70
H35.711H35.712H35.713H35.721H35.722H35.723H35.731
H35.732H35.733H35.81H35.82H35.89H36H44.2A1
H44.2A2H44.2A3H44.2B1H44.2B2H44.2B3H44.2C1H44.2C2
H44.2C3H44.2D1H44.2D2H44.2D3H44.2E1H44.2E2H44.2E3
H46.01H46.02H46.03H46.11H46.12H46.13H46.2
H46.3H46.8H46.9H47.011H47.012H47.013H47.021
H47.022H47.023H47.031H47.032H47.033H47.091H47.092
H47.093H47.10H47.11H47.12H47.13H47.141H47.142
H47.143H47.20H47.211H47.212H47.213H47.22H47.231
H47.232H47.233H47.291H47.292H47.293H47.311H47.312
H47.313H47.321H47.322H47.323H47.331H47.332H47.333
H47.391H47.392H47.393H53.10H53.11H53.121H53.122
H53.123H53.131H53.132H53.133H53.15H53.16H53.19
H53.411H53.412H53.413H53.451H53.452H53.453H53.51
H53.52H53.60H53.61H53.62H53.63H53.69H53.71
H53.72H53.8H53.9H54.0X33H54.0X34H54.0X35H54.0X43
H54.0X44H54.0X45H54.0X53H54.0X54H54.0X55H54.1131H54.1132
H54.1141H54.1142H54.1151H54.1152H54.1213H54.1214H54.1215
H54.1223H54.1224H54.1225H54.2X11H54.2X12H54.2X21H54.2X22
H54.413AH54.414AH54.415AH54.42A3H54.42A4H54.42A5H54.511A
H54.512AH54.52A1H54.52A2H54.7S04.011AS04.011DS04.011S
S04.012AS04.012DS04.012SS05.51XAS05.51XDS05.51XSS05.52XA
S05.52XDS05.52XS

Non-Covered Diagnosis Codes for Procedure Codes 0509T, 92273 and 92274

H40.10X0H40.10X1H40.10X2H40.10X3H40.10X4H40.1110H40.1111
H40.1112H40.1113H40.1114H40.1120H40.1121H40.1122H40.1123
H40.1124H40.1130H40.1131H40.1132H40.1133H40.1134H40.1190
H40.1191H40.1192H40.1193H40.1194H40.1210H40.1211H40.1212
H40.1213H40.1214H40.1220H40.1221H40.1222H40.1223H40.1224
H40.1230H40.1231H40.1232H40.1234H40.1290H40.1291H40.1292
H40.1293H40.1294H40.1310H40.1311H40.1312H40.1313H40.1314
H40.1320H40.1321H40.1322H40.1323H40.1324H40.1330H40.1331
H40.1332H40.1333H40.1334H40.1390H40.1391H40.1392H40.1393
H40.1394H40.1410H40.1411H40.1412H40.1413H40.1414H40.1420
H40.1421H40.1422H40.1423H40.1424H40.1430H40.1431H40.1432
H40.1433H40.1434H40.1490H40.1491H40.1492H40.1493H40.1494
H40.151H40.152H40.153H40.159H40.20X0H40.20X1H40.20X2
H40.20X3H40.20X4H40.211H40.212H40.213H40.219H40.2210
H40.2211H40.2212H40.2213H40.2214H40.2220H40.2221H40.2222
H40.2223H40.2224H40.2230H40.2231H40.2232H40.2233H40.2234
H40.2290H40.2291H40.2292H40.2293H40.2294H40.231H40.232
H40.233H40.239H40.241H40.242H40.243H40.249H40.30X0
H40.30X1H40.30X2H40.30X3H40.30X4H40.31X0H40.31X1H40.31X2
H40.31X3H40.31X4H40.32X0H40.32X1H40.32X2H40.32X3H40.32X4
H40.33X0H40.33X1H40.33X2H40.33X3H40.33X4H40.40X0H40.40X1
H40.40X2H40.40X3H40.40X4H40.41X0H40.41X1H40.41X2H40.41X3
H40.41X4H40.42X0H40.42X1H40.42X2H40.42X3H40.42X4H40.43X0
H40.43X1H40.43X2H40.43X3H40.43X4H40.50X0H40.50X1H40.50X2
H40.50X3H40.50X4H40.51X0H40.51X1H40.51X2H40.51X3H40.51X4
H40.52X0H40.52X1H40.52X2H40.52X3H40.52X4H40.53X0H40.53X1
H40.53X2H40.53X3H40.53X4H40.60X0H40.60X1H40.60X2H40.60X3
H40.60X4H40.61X0H40.61X1H40.61X2H40.61X3H40.61X4H40.62X0
H40.62X1H40.62X2H40.62X3H40.62X4H40.63X0H40.63X1H40.63X2
H40.63X3H40.63X4H40.811H40.812H40.813H40.819H40.821
H40.822H40.823H40.829H40.831H40.832H40.833H40.839
H40.89H40.9H42Q15.0

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