H10.421 — Simple chronic conjunctivitis, right eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record must include the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
- The office visit record or operative report must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
- Claims must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and the reason(s) for the service.
- For excisions, document the greatest clinical diameter of the lesion plus the margin required (measurement made prior to excision) and the rationale for choosing excision if not cosmetic.
Key Coverage Criteria
- Excision of a benign skin lesion is covered when there is clinical suspicion of malignancy (e.g., ICD-10-CM D48.5) documented in the medical record.
- Removal is covered to address disturbance of skin sensation when documented (ICD-10-CM R20.0-R20.3, R20.8).
- Removal is covered when documented objective changes (e.g., increase in size) support a diagnosis warranting excision.
- Removal of a benign lesion is covered when the treating physician documents medical necessity for removal (physician judgment that lesion merits removal).
- 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.
7 Active Policies
AMBETTER-CP.VP.43 — External Ocular Photography
A57044 — Billing and Coding: Removal of Benign Skin Lesions
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
Related Codes
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