Does H40.40X1 require prior authorization?

No, H40.40X1 does not require prior authorization (high confidence). Covered without prior authorization.

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`H40.40X1`, Glaucoma secondary to eye inflammation, unspecified eye, mild stage

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must include the referring/ordering physician's name and NPI when required by the service, and all same-day services for the same beneficiary by the same provider must be billed on the same claim.
Medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests, and a signed and dated office visit/operative report.
For fundus photography, retain a copy of the photographs in the record, include an interpretation and report, document whether the pupil was dilated and which drug was used, and maintain legible documentation of medical necessity.

For extended ophthalmoscopy, retain a detailed per-eye retinal drawing (minimum 3–4 inches, labeled; 4–6 colors preferred), document optic nerve drawings for glaucoma with cupping/disc rim/pallor/slope and surrounding pathology, note method of examination and pupil dilation/drug, and document findings and plan.

When reporting non-covered services per ABN guidance, use appropriate G modifiers (-GA, -GX, -GY, -GZ) and retain signed ABN Form CMS-R-131 when applicable; for Part A MAC claims, include occurrence code 32 and the ABN date when GA is used.

Key Coverage Criteria

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.
When extended ophthalmoscopy is performed during a global surgical period and is unrelated to the surgery (same provider), bill the extended ophthalmoscopy with modifier 79 (and the appropriate site modifier if unilateral).
Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
Fundus photography may be used to diagnose or document macular degeneration.

5 Active Policies

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

J15

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

J18

FIRST_COAST-L33766, Visual Field Examination

A57637, Billing and Coding: Visual Field Examination

A57071, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

`H40.40X1`, Glaucoma secondary to eye inflammation, unspecified eye, mild stage

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

H40.40X1, Glaucoma secondary to eye inflammation, unspecified eye, mild stage

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`H40.40X1`, Glaucoma secondary to eye inflammation, unspecified eye, mild stage