D31.20 — Benign neoplasm of unspecified retina
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must include the referring/ordering physician's name and NPI when required by the service, and all same-day services for the same beneficiary by the same provider must be billed on the same claim.
- Medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests, and a signed and dated office visit/operative report.
- For fundus photography, retain a copy of the photographs in the record, include an interpretation and report, document whether the pupil was dilated and which drug was used, and maintain legible documentation of medical necessity.
- For extended ophthalmoscopy, retain a detailed per-eye retinal drawing (minimum 3–4 inches, labeled; 4–6 colors preferred), document optic nerve drawings for glaucoma with cupping/disc rim/pallor/slope and surrounding pathology, note method of examination and pupil dilation/drug, and document findings and plan.
Key Coverage Criteria
- Fundus photography (CPT 92250, 92228) is covered when medical necessity is documented in the patient's medical record including relevant history, physical exam, results of pertinent tests, an interpretation/report, and retained copies of the photographs.
- Extended ophthalmoscopy (CPT 92201, 92202) is covered when medical necessity is documented per-eye with a retinal drawing that meets the policy specifications, relevant history, physical exam, and test results recorded.
- Professional (26) and/or technical (TC) components of fundus photography CPT 92250 and 92228 may be billed separately when only one component is performed, with the appropriate modifier reported.
- When extended ophthalmoscopy is performed during a global surgical period and is unrelated to the surgery (same provider), bill the extended ophthalmoscopy with modifier 79 (and the appropriate site modifier if unilateral).
- Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
- Peripheral nerve blocks are covered when they meet the reasonable and necessary requirements specified in LCD L33933.
8 Active Policies
A57637 — Billing and Coding: Visual Field Examination
J09
L33766 — Visual Field Examination
J09
A57071 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
AETNA-CPB-0344 — Optic Nerve and Retinal Imaging Methods
L34399 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
Related Codes
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