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ICD-10-CM H54.1213, Low vision right eye category 1, blindness left eye category 3 | No Prior Auth

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`H54.1213`, Low vision right eye category 1, blindness left eye category 3

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

For fundus photography, the medical record must document relevant medical history, physical examination, pertinent diagnostic test results, retention of the photographs, an interpretation/report, whether the pupil was dilated, and which drug was used; records must be legible and available to the carrier.

For extended ophthalmoscopy the record must include relevant history, physical exam, pertinent diagnostic results, retinal drawings meeting Appendix A specifications (separate detailed sketch 3-4 inches, labeled, colors preferred), and documentation of the method of examination and pupil dilation/drug; records must be legible and available.

Key Coverage Criteria

Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.
Conditions including tuberculosis of eye (A18.53, A18.54), diabetes mellitus with ophthalmic complications (E08.311-E08.359, E09.311-E09.359, E10.311-E10.359, E11.311-E11.359, E13.311-E13.359), ophthalmia nodosa (H16.241-H16.249), selected anterior segment disorders (H20.00-H21.1X1), and transient cerebral ischemic attacks with ocular involvement (G45.3) may require extended ophthalmoscopy and are covered.
Malignant and secondary neoplasms of the eye and adnexa (C69.20-C69.42, C79.89-C79.9) and benign neoplasms of the eye and adnexa (D31.20-D31.32) may require and are covered for extended ophthalmoscopy.
Other ocular conditions generally requiring monitoring may be covered for extended ophthalmoscopy when documentation supports medical necessity, subject to specified frequency limits.

20 Active Policies

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

A57483, Billing and Coding: Visual Fields

J5

A57599, Billing and Coding: Visual Electrophysiology Testing

J5

WPS-J5-L34615, Visual Fields

J5

WPS-J5-L37015, Visual Electrophysiology Testing

J5

A56551, Billing and Coding: Visual Fields Testing

J6

NGS-J6-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J6

A57060, Billing and Coding: Visual Electrophysiology Testing

J6

NGS-J6-L33574, Visual Fields Testing

J6

NGS-J6-L36831, Visual Electrophysiology Testing

J6

A56726, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J6

WPS-J8-L37015, Visual Electrophysiology Testing

J8

WPS-J8-L34615, Visual Fields

J8

A57677, Billing and Coding: Electroretinography (ERG)

J9

FIRST_COAST-L33766, Visual Field Examination

J9

FIRST_COAST-L37398, Electroretinography (ERG)

J9

A57637, Billing and Coding: Visual Field Examination

J9

NOVITAS-JH-L37371, Electroretinography (ERG)

JH

NGS-JK-L33574, Visual Fields Testing

JK

Related Codes

E08.3293(20 policies)E08.3213(20 policies)E08.3292(20 policies)E08.3291(20 policies)E08.3212(20 policies)A18.53(20 policies)E08.3211(20 policies)E08.3311(20 policies)

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