H11.001 — Unspecified pterygium of right eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The diagnosis code(s) billed must best describe the patient’s condition for which the SCODI service was performed.
- The patient's medical record must contain documentation that fully supports the medical necessity for SCODI services included within LCD L34380, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- For diagnostic tests, report the test result on the claim if known; if the result is not known at time of billing, report the symptoms that prompted the test.
Key Coverage Criteria
- Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
- Computerized corneal topography is billable when performed as a diagnostic test for corneal conditions and the claim includes a diagnosis code that best describes the patient's condition for which the service was performed.
- 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.
- Pre-operative corneal topography for intraocular lens power determination in cataract surgery when irregular astigmatism is present.
9 Active Policies
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
ANTHEM-CG-SURG-127 — CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
A56816 — Billing and Coding: Computerized Corneal Topography
A57068
Related Codes
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