Does H04.431 require prior authorization?

No, H04.431 does not require prior authorization (high confidence). Covered without prior authorization.

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`H04.431`, Chronic lacrimal mucocele of right lacrimal passage

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.
An interpretation and report specific to the photograph(s), including comparison to prior photographs when available, must be maintained in the medical record and available to the contractor upon request.
If additional photographs are taken to track changes, written documentation describing those changes must be maintained in the patient's medical record.

Key Coverage Criteria

External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.
External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
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.

8 Active Policies

CGS-J15-L34171, Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation

J15

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34171, Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation

J18

CGS-J18-L34393, Ocular Photography - External

J18

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H04.431, Chronic lacrimal mucocele of right lacrimal passage