Does Q14.1 require prior authorization?

No, Q14.1 does not require prior authorization (high confidence). Covered without prior authorization.

`Q14.1`, Congenital malformation of retina

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Document general ophthalmoscopy and biomicroscopy findings in the medical record even when these services are included in extended ophthalmoscopy and not separately billed.
For extended ophthalmoscopy, include a drawing or equivalent documentation that demonstrates the extended nature of the exam to support separate payment.
Orders for CPT 92227 and CPT 92228 must be from the treating physician or other treating practitioner acting within the scope of license and Medicare requirements and this order must be documented in the record.
When extended ophthalmoscopy is performed during a global surgery period and is unrelated to the surgical condition, document the unrelatedness and report modifier -76 or -79 as appropriate.

Extended ophthalmoscopy (CPT 92201, 92202) is payable when documented as an extended ophthalmoscopy that meets indicated standards (e.g., includes a retinal drawing or equivalent documentation) beyond a general ophthalmologic exam.
Fundus photography (CPT 92227, CPT 92228) is covered when ordered by the treating physician or other treating practitioner acting within the scope of his/her license and Medicare requirements.
CPT 92227 is covered when used to evaluate asymptomatic patients at risk with known disease likely to cause retinal disease (e.g., diabetes mellitus) when ordered by the treating physician.
CPT 92228 is a covered service when ordered by the treating physician or other treating practitioner acting within the scope of license and Medicare requirements.
Speech-language pathology (SLP) services for treatment or evaluation of communication disorders when determined reasonable and necessary per LCD L35070.
Selection and prescription of speech-generating devices should be billed with CPT code 92607.

CGS-J15-L34394, Visual Fields Testing

J15

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

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.