Does H04.213 require prior authorization?

No, H04.213 does not require prior authorization (high confidence). No active policy covers this code.

`H04.213`, Epiphora due to excess lacrimation, bilateral lacrimal glands

ICD-10-CM

No Prior Auth Required

No active policy covers this code (high confidence)

The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit, relevant medical history, and results of pertinent tests or procedures.
A signed and dated office visit record or operative report is required for all services (all services ordered or rendered to Medicare beneficiaries must be signed).
For claims requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
For diagnostic tests, report the test result if known; otherwise report the symptom(s) that prompted the test; for hospital inpatient claims the principal diagnosis must be reported in FL67 and admitting diagnosis in FL69, and for outpatient hospital claims report the full ICD-10-CM code in FL67 or a symptom code if no definitive diagnosis.

CPT codes 68801, 68810 and 68840 are payable under Medicare Part B when medically necessary and performed in the following places of service: office (11), assisted living facility (13), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility (Part A stay) (31), nursing facility not in a Part A stay (32), custodial care facility (33), and independent clinic (49).
CPT codes 68811 and 68815 are payable under Medicare Part B when medically necessary and performed in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), and independent clinic (49).
Procedures represented by CPT 68801, 68810-68815, and 68840 are covered only when reasonable and necessary for the patient's nasolacrimal punctum or nasolacrimal duct condition, supported by appropriate clinical documentation and diagnosis codes.

A57284, Billing and Coding: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation

Ask Backwork about documentation requirements, denial risks, or coverage in your state.