Summary & Overview
HCPCS Level II M1428: Bilateral Absence of Eyes
HCPCS Level II code M1428 designates patients with a bilateral absence of eyes documented at any point during the patient’s history through the end of the measurement period. As a status and measurement code, it captures a rare but clinically important condition that has implications for long-term care planning, habilitation, adaptive services, and population health reporting. Nationally, accurate use of this code supports epidemiologic tracking, resource allocation for vision impairment services, and coordination of multidisciplinary care.
This publication covers major payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical context, typical sites of service, and the kinds of documentation tied to this status indicator. The report also summarizes available benchmarks and policy considerations where applicable, clarifies measurement intent, and highlights how the code integrates with broader disability and vision-impairment reporting frameworks. Data not available in the input.
Billing Code Overview
HCPCS Level II code M1428 identifies patients who have bilateral absence of eyes at any time during the patient’s history through the end of the measurement period. This code documents a congenital or acquired condition involving absence of both eyes and is used to record the patient status for measurement and reporting purposes.
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Service type: Diagnostic/status reporting related to ocular absence, used in patient records and measurement registries.
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Typical site of service: Outpatient clinics, ophthalmology practices, specialized habilitation or low-vision centers, and institutional patient records where ocular status is documented.
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Clinical & Coding Specifications
Clinical Context
A patient with a lifelong history of bilateral absence of eyes (anophthalmia) presents for annual prosthetic assessment and medical record documentation. The patient is an adult who was born with bilateral anophthalmia and uses ocular conformers and facial prostheses. The clinical workflow includes: initial intake and verification of identity and insurance, review of past medical and surgical history, physical examination of the orbital sockets and surrounding adnexa, assessment for socket growth or contracture, evaluation of prosthesis fit and need for new ocular prostheses or conformers, coordination with ocularistry or maxillofacial prosthetics, ordering of supportive services as needed (e.g., orbital imaging if structural issues suspected), documentation of the bilateral congenital absence of eyes for quality measures and billing purposes using M1428, and scheduling follow-up appointments. Typical encounters occur in ophthalmology clinics, ocularistry or maxillofacial prosthetics departments, and ambulatory surgical centers when surgical socket reconstruction is required. Payors commonly involved include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when an E/M visit is medically necessary and distinct from prosthetic fitting or minor procedure on the same day |