Does S02.42XA require prior authorization?

No, S02.42XA does not require prior authorization (high confidence). Covered without prior authorization.

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`S02.42XA`, Fracture of alveolus of maxilla, initial encounter for closed fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.

An interpretation and report specific to the photograph(s), including comparison to prior photographs when available, must be maintained in the medical record and available to the contractor upon request.

If additional photographs are taken to track changes, written documentation describing those changes must be maintained in the patient's medical record.

For claims requiring an ABN, Form CMS-R-131 must be signed by the beneficiary (or properly witnessed refusal) and for Part A claims occurrence code 32 and the ABN date must be reported.

Key Coverage Criteria

External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.
External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
External ocular photography is covered when photo-documentation is required to track progression or lack of progression of an eye condition or to document response or progression related to a course of treatment.

5 Active Policies

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34393, Ocular Photography - External

J18

A56612, Billing and Coding: CT of the Head

A57068, Billing and Coding: Ocular Photography - External

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

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S02.42XA, Fracture of alveolus of maxilla, initial encounter for closed fracture