Does T26.40XA require prior authorization?

No, T26.40XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T26.40XA`, Burn of unspecified eye and adnexa, part unspecified, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

List the appropriate CPT code for the procedure and include any applicable modifiers; adhere to Medicare global surgery and CCI (correct coding initiative) rules for eyelid surgeries.
Submit physicians' services and diagnostic tests with a diagnosis code that supports medical necessity and code to the greatest level of specificity (full digit completeness).
Use the diagnosis code based on diagnostic test results as the primary diagnosis; if test results are normal or inconclusive, use the diagnosis code for the sign or symptom that prompted the test as the primary diagnosis.

When signs or symptoms are present, place the appropriate definitive diagnosis code in the first position and an available symptom diagnosis code in the second position on CMS-1500 item 21 (or electronic equivalent).

When a patient requests submission of cosmetic services to Medicare, report with modifier GY and place ICD-10 code Z41.1 in the first diagnosis position on the claim; consider issuing a Notice of Exclusion from Medicare Benefits (NEMB) as appropriate.

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.

Key Coverage Criteria

Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
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.
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
Margin reflex distance (MRD) of 2.5 mm or less (measured from corneal light reflex to upper eyelid margin with brows relaxed) meets criteria for ptosis surgery.

10 Active Policies

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34393, Ocular Photography - External

J18

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

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

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

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

A57068, Billing and Coding: Ocular Photography - External

A59186, Billing and Coding: Magnesium

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T26.40XA, Burn of unspecified eye and adnexa, part unspecified, initial encounter