Does A51.43 require prior authorization?

No, A51.43 does not require prior authorization (high confidence). Code is covered without prior authorization.

`A51.43` — Secondary syphilitic oculopathy

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
When extended ophthalmoscopy is performed during a global surgery period and is unrelated to the surgical condition, document the unrelatedness and report modifier -76 or -79 as appropriate.

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.
Fundus photography is medically necessary when it will assist in monitoring progression of an eye disease or in guiding the need for or response to a specific treatment or intervention.
Fundus photography is medically necessary to provide comparison photos to detect progression in conditions such as diabetic retinopathy, advanced non-neovascular macular degeneration with suspicious areas, or evaluation of a nevus/tumor for change.

AMBETTER-CP.VP.29 — Fundus Photography

ANTHEM-CG-MED-47 — CG-MED-47 Fundus Photography

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

L33467 — Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

Ask Verity about documentation requirements, denial risks, or coverage in your state.