H02.881 — Meibomian gland dysfunction right upper eyelid
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must include the ordering/provider assessment related to the patient's complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For Group 2 ICD-10-CM and Group 2 CPT codes, documentation must include visual field results and/or photographs supporting functional impairment.
- For induction of visually compromising dermatochalasis by ptosis repair with large levator aponeurosis dehiscence, documentation must show the dehiscence and an operative note indicating skin excess after ptosis repair and necessity of blepharoplasty.
- When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI; diagnostic test claims should report the test result or the symptoms prompting the test if the result is unknown.
Key Coverage Criteria
- 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.
- Blepharoplasty may be covered when visually compromising dermatochalasis is induced by ptosis repair in patients with large levator aponeurosis dehiscence if documentation shows the dehiscence and an operative note documents residual skin excess after ptosis repair that makes blepharoplasty necessary.
- Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
- For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
- If the service requires a referring/ordering physician, include the ordering/referring physician’s name and NPI on the claim.
11 Active Policies
L33766 — Visual Field Examination
J09
A57637 — Billing and Coding: Visual Field Examination
J09
A56799 — Billing and Coding: Visual Fields Testing
A57044 — Billing and Coding: Removal of Benign Skin Lesions
A57068 — Billing and Coding: Ocular Photography - External
Related Codes
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