Does Q87.89 require prior authorization?

No, Q87.89 does not require prior authorization (high confidence). Covered without prior authorization.

Backwork Sign up free

`Q87.89`, Other specified congenital malformation syndromes, not elsewhere classified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

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

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.
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.

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

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

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

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

ANTHEM-CG-SURG-90, Mohs Micrographic Surgery

AMBETTER-CG-Hered-CA-Suscep-2025.1, Concert Genetic Testing: Hereditary Cancer Susceptibility

AETNA-CPB-0107, Chiropractic Services

A53060, Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

ANTHEM-CG-MED-47, Fundus Photography

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

Have a follow-up question?

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

Ask Backwork about Q87.89 Sign up free

Q87.89, Other specified congenital malformation syndromes, not elsewhere classified