Does T85.21XA require prior authorization?

No, T85.21XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T85.21XA`, Breakdown (mechanical) of intraocular lens, 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.
Blepharoplasty is covered when medical necessity is documented in the medical record, including relevant history, physical exam, and diagnostic test results that support the procedure per the applicable LCD.
For Group 2 ICD-10-CM/CPT codes, coverage requires documentation of visual field testing results and/or photographs demonstrating functional visual impairment from eyelid pathology.

20 Active Policies

CGS-J15-L33944, Blepharoplasty

J15

CGS-J15-L33946, Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy

J15

CGS-J15-L34008, Computerized Corneal Topography

J15

CGS-J15-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J15

CGS-J18-L34008, Computerized Corneal Topography

J18

CGS-J18-L33944, Blepharoplasty

J18

CGS-J18-L33946, Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy

J18

CGS-J18-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J18

WPS-J5-L34760, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A56916, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

NGS-J6-L33621, Ophthalmic Biometry for Intraocular Lens Power Calculation

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

A56549, Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation

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

WPS-J8-L34760, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

NGS-JK-L33621, Ophthalmic Biometry for Intraocular Lens Power Calculation

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

CIGNA-0125, Intraocular Lens Implant

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

A56439, Billing and Coding: Blepharoplasty

`T85.21XA`, Breakdown (mechanical) of intraocular lens, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T85.21XA, Breakdown (mechanical) of intraocular lens, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T85.21XA`, Breakdown (mechanical) of intraocular lens, initial encounter