H04.563 — Stenosis of bilateral lacrimal punctum
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
- All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.
- An interpretation and report specific to the photograph(s), including comparison to prior photographs when available, must be maintained in the medical record and available to the contractor upon request.
- If additional photographs are taken to track changes, written documentation describing those changes must be maintained in the patient's medical record.
Key Coverage Criteria
- 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.
- 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.
4 Active Policies
A57068 — Billing and Coding: Ocular Photography - External
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
L34393 — Ocular Photography - External
Related Codes
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