Does S05.20XA require prior authorization?

No, S05.20XA does not require prior authorization (high confidence). Covered without prior authorization.

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`S05.20XA`, Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

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.

For a diagnosis of glaucoma (ICD H40.001-H40.152) documentation must include a separate detailed optic nerve drawing with an interpretation that affects treatment, and documentation of cupping, disc rim, pallor, slope, and any surrounding pathology.

Key Coverage Criteria

Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
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.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.
Conditions including tuberculosis of eye (A18.53, A18.54), diabetes mellitus with ophthalmic complications (E08.311-E08.359, E09.311-E09.359, E10.311-E10.359, E11.311-E11.359, E13.311-E13.359), ophthalmia nodosa (H16.241-H16.249), selected anterior segment disorders (H20.00-H21.1X1), and transient cerebral ischemic attacks with ocular involvement (G45.3) may require extended ophthalmoscopy and are covered.
Malignant and secondary neoplasms of the eye and adnexa (C69.20-C69.42, C79.89-C79.9) and benign neoplasms of the eye and adnexa (D31.20-D31.32) may require and are covered for extended ophthalmoscopy.

13 Active Policies

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

WPS-J5-L34771, Immune Globulins

A56908, Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

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

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

WPS-J8-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

WPS-J8-L34771, Immune Globulins

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

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

ANTHEM-CG-SURG-03, Blepharoplasty, Blepharoptosis Repair, and Brow Lift

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S05.20XA, Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial encounter