Does S05.12XA require prior authorization?

No, S05.12XA does not require prior authorization (high confidence). Covered without prior authorization.

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`S05.12XA`, Contusion of eyeball and orbital tissues, left eye, initial encounter

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.

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.
A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

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

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

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

A56537, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A57637, Billing and Coding: Visual Field Examination

FIRST_COAST-L33766, Visual Field Examination

NGS-JK-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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

AMBETTER-CP.VP.63, Visual Field Testing

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

A56459, Billing and Coding: Debridement Services

AMBETTER-CP.VP.31, Gonioscopy

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

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

AMBETTER-CP.VP.26, Extended Ophthalmoscopy

AMBETTER-CP.VP.14, Scanning Computerized Opthalmic Diagnostic Imaging

`S05.12XA`, Contusion of eyeball and orbital tissues, left eye, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

S05.12XA, Contusion of eyeball and orbital tissues, left eye, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`S05.12XA`, Contusion of eyeball and orbital tissues, left eye, initial encounter