Does H35.9 require prior authorization?

No, H35.9 does not require prior authorization (high confidence). Covered without prior authorization.

`H35.9`, Unspecified retinal disorder

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.
Documentation should include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures supporting the need for visual fields testing.
The diagnosis code(s) reported on the claim must best describe the patient's condition for which the visual fields testing was performed.
Refer to NCCI and OPPS requirements prior to billing Medicare to ensure coding compliance and to determine any bundling or packaging edits.

Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
If the service requires a referring/ordering physician, include the ordering/referring physician’s name and NPI on the claim.
Fundus photography (CPT 92250, 92228) is covered when medical necessity is documented in the patient's medical record including relevant history, physical exam, results of pertinent tests, an interpretation/report, and retained copies of the photographs.
Extended ophthalmoscopy (CPT 92201, 92202) is covered when medical necessity is documented per-eye with a retinal drawing that meets the policy specifications, relevant history, physical exam, and test results recorded.
Professional (26) and/or technical (TC) components of fundus photography CPT 92250 and 92228 may be billed separately when only one component is performed, with the appropriate modifier reported.

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

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