M1328 Acute Vitreous Hemorrhage | HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1328: Acute Vitreous Hemorrhage Evaluation

HCPCS Level II code M1328 designates care for patients diagnosed with acute vitreous hemorrhage, a sudden bleed into the vitreous cavity that can cause rapid visual decline and often prompts urgent ophthalmic evaluation. Nationally, coding clarity for acute ocular emergencies influences access to timely diagnostic and therapeutic services and supports consistent claims processing for emergency eye care. Key payers included in this overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an orientation to the code’s clinical context, typical sites of service, and the types of documentation and billing scenarios in which M1328 is used. The publication also outlines common benchmarking topics and policy considerations relevant to payers and providers, including service line placement within ophthalmology and emergency care workflows. Where available, the report summarizes typical payer handling, reimbursement themes, and coding caveats that affect national claim adjudication for acute vitreous hemorrhage. Data not available in the input will be noted as such in relevant sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1328HCPCS Level IIophthalmologyacute vitreous hemorrhageemergency ophthalmic careambulatory surgeryhospital emergency departmentmedical billing

Billing Code Overview

HCPCS Level II code M1328 identifies patients with a diagnosis of acute vitreous hemorrhage. This code denotes services related to the evaluation and management of a sudden-onset intraocular hemorrhage within the vitreous body of the eye.

Service Type: Ophthalmic emergency/urgent evaluation and management

Typical Site of Service: Hospital emergency department, ophthalmology clinic, or ambulatory surgical center

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 68-year-old patient presents to a retinal specialist with sudden onset vision loss and complaints of floaters and a dark curtain in the visual field. Examination with slit lamp and dilated fundus exam suggests an acute vitreous hemorrhage obscuring fundus details. B-scan ocular ultrasonography confirms vitreous blood with no clear retinal detachment. The patient is counseled about observation versus surgical intervention. Initial management often includes outpatient evaluation with activity modification and head positioning while ordering baseline labs and anticoagulation review. If hemorrhage fails to clear or if there is associated tractional or rhegmatogenous retinal detachment, pars plana vitrectomy is scheduled in an operating room under monitored anesthesia care or general anesthesia. Typical sites of service include ambulatory surgical centers and hospital operating rooms. Perioperative workflow includes preoperative evaluation, anesthesia documentation, intraoperative vitrectomy procedure notes, and postoperative follow-up visits documenting visual acuity, intraocular pressure, and retinal status.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than typical for the procedure due to complexity (document rationale).
`23`

HCPCS Level II M1427: Documentation of Medical Reason for Bone Scan

HCPCS-M1446-PATIENT-DEATH-DURING-MEASURE-PERIOD

HCPCS Level II M1446: Patient Death During Measure Assessment Period

HCPCS-M1345-PAM-SCORE-FOLLOW-UP-4-12-MONTHS

HCPCS M1345: Follow-up Patient Activation Measure (4–12 Months)

HCPCS-M1329-POST-OPERATIVE-ACUTE-PVD-EYE-ENCOUNTER

HCPCS M1329: Post-Operative Encounter for Acute Posterior Vitreous Detachment

HCPCS-M1310-TOBACCO-CESSATION-SCREENING-AND-INTERVENTION

HCPCS Level II M1310: Tobacco Use Screening and Cessation Intervention

HCPCS-M1148-PATIENT-SELF-DISCHARGED-ONGOING-CARE-NOT-POSSIBLE

HCPCS Level II M1148: Ongoing Care Not Possible Due to Patient Self-Discharge

HCPCS-M1422-GASTROENTEROLOGY-MIPS-VALUE-PATHWAY

HCPCS M1422: Gastroenterology Care MIPS Value Pathway

HCPCS-M1322-POST-INJECTION-IOP-SCREENING

HCPCS Level II M1322: Post-Injection IOP Screening

HCPCS-M1466-LUMBAR-FUSION-WITH-DISCECTOMY-LAMINECTOMY

HCPCS Level II M1466: Lumbar Fusion with Discectomy/Laminectomy

HCPCS-M1433-ORAL-CHEMOTHERAPY-EXPOSURE

HCPCS M1433: Oral Chemotherapy Exposure, 30-Day Window

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Taxonomy Code	Specialty	Notes
`252S00000X`	Ophthalmology	Retinal specialists (vitreoretinal surgeons) perform vitrectomy for vitreous hemorrhage.
`207R00000X`	Ophthalmic Plastic and Reconstructive Surgery	May be involved for orbit-related complications or combined anterior segment issues.
`163W00000X`	Anesthesiology	Anesthesiologists provide general or monitored anesthesia care for OR vitrectomy cases.
`363A00000X`	Optometry	Optometrists may perform initial triage and postoperative co-management under collaborative agreements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H43.11`	Vitreous hemorrhage, right eye	Direct diagnosis indicating acute vitreous bleeding in the right eye, primary reason for vitrectomy or observation.
`H43.12`	Vitreous hemorrhage, left eye	Direct diagnosis indicating acute vitreous bleeding in the left eye.
`H43.119`	Vitreous hemorrhage, unspecified eye	Used when laterality is not specified in documentation.
`H35.031`	Nonproliferative diabetic retinopathy, right eye	Diabetes-related retinopathy is a common cause of vitreous hemorrhage and may necessitate vitrectomy.
`H35.032`	Nonproliferative diabetic retinopathy, left eye	As above for the left eye.
`H35.051`	Proliferative diabetic retinopathy, right eye	Proliferative disease with neovascularization is a frequent cause of vitreous hemorrhage requiring surgical intervention.
`H35.052`	Proliferative diabetic retinopathy, left eye	As above for the left eye.
`S05.11XA`	Contusion of eyeball, right eye, initial encounter	Trauma-related vitreous hemorrhage coding when hemorrhage follows blunt ocular trauma.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`67036`	Vitrectomy, pars plana; for removal of vitreous opacities (separate procedure)	Commonly used for pars plana vitrectomy performed to clear dense vitreous hemorrhage.
`67039`	Vitrectomy, pars plana; with removal of subretinal membrane and/or scar tissue	Used when additional membrane peeling or scar tissue removal is required during vitrectomy for hemorrhage.
`67040`	Vitrectomy, pars plana; with retinal detachment repair and/or injection of long-acting tamponade (e.g., scleral buckling may be coded separately)	Applicable when vitreous hemorrhage is associated with or converted to retinal detachment requiring repair during the same surgical encounter.
`67028`	Intravitreal injection of a pharmacologic agent (separate procedure)	May be performed pre- or postoperatively to treat underlying causes such as proliferative diabetic retinopathy.
`67015`	Photocoagulation of retina (panretinal)	Panretinal photocoagulation is commonly performed before or after vitrectomy to control neovascularization causing hemorrhage.

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