Does M08.40 require prior authorization?

No, M08.40 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M08.40`, Pauciarticular juvenile rheumatoid arthritis, unspecified site

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium 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.

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).
Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.

11 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

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

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

`M08.40`, Pauciarticular juvenile rheumatoid arthritis, unspecified site

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

M08.40, Pauciarticular juvenile rheumatoid arthritis, unspecified site

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`M08.40`, Pauciarticular juvenile rheumatoid arthritis, unspecified site