H04.221 — Epiphora due to insufficient drainage, right side
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit, relevant medical history, and results of pertinent tests or procedures.
- A signed and dated office visit record or operative report is required for all services (all services ordered or rendered to Medicare beneficiaries must be signed).
- For claims requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- For diagnostic tests, report the test result if known; otherwise report the symptom(s) that prompted the test; for hospital inpatient claims the principal diagnosis must be reported in FL67 and admitting diagnosis in FL69, and for outpatient hospital claims report the full ICD-10-CM code in FL67 or a symptom code if no definitive diagnosis.
Key Coverage Criteria
- CPT codes 68801, 68810 and 68840 are payable under Medicare Part B when medically necessary and performed in the following places of service: office (11), assisted living facility (13), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility (Part A stay) (31), nursing facility not in a Part A stay (32), custodial care facility (33), and independent clinic (49).
- CPT codes 68811 and 68815 are payable under Medicare Part B when medically necessary and performed in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), and independent clinic (49).
- Procedures represented by CPT 68801, 68810-68815, and 68840 are covered only when reasonable and necessary for the patient's nasolacrimal punctum or nasolacrimal duct condition, supported by appropriate clinical documentation and diagnosis codes.
- Dilation of the punctum and/or probing of the nasolacrimal duct is reasonable when obstruction at or distal to the lacrimal puncta is reasonably suspected to be causing epiphora or chronic dacryocystitis and the procedure is required to alleviate symptoms or reduce infection/damage.
- Epiphora due to acquired obstruction within the nasolacrimal sac and/or nasolacrimal duct is an indication for dilation and/or probing.
- Mucocele of the lacrimal sac is an indication for nasolacrimal punctal dilation and/or duct probing.
3 Active Policies
AETNA-CPB-0420 — Nasolacrimal Duct Obstruction: Treatments
A57284 — Billing and Coding: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
L34171 — Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
Related Codes
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