H02.153 — Paralytic ectropion of right eye, unspecified eyelid
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For claims requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- The medical record must include the ordering provider's assessment related to the visit, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit or operative report.
- For botulinum toxin coverage, medical records must document medical necessity for treatment.
- For spastic conditions other than upper limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation must state the condition was unresponsive to conventional treatment and include the covered diagnosis, dosages, injection sites, frequencies, EMG necessity if used, and description of treatment effectiveness.
Key Coverage Criteria
- Medicare covers botulinum toxin injections for medically necessary treatment of spastic conditions including upper limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia, and other focal dystonias.
- Medicare will reimburse unused portions of reconstituted botulinum toxin when the medical record documents the precise amount administered and the amount discarded.
- 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.
- Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
6 Active Policies
A57637 — Billing and Coding: Visual Field Examination
J09
L33766 — Visual Field Examination
J09
A56472 — Billing and Coding: Botulinum Toxins
A57068 — Billing and Coding: Ocular Photography - External
L34393 — Ocular Photography - External
Related Codes
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