H11.431 — Conjunctival hyperemia, right eye
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.
- External ocular photography is covered when photo-documentation is required to track progression or lack of progression of an eye condition or to document response or progression related to a course of treatment.
- External ocular photography is covered when a special camera is used to obtain magnified medical-quality photographs of lesions (e.g., cornea, iris, eyelids) for the purpose of following the patient's condition.
- Assessment of anterior chamber angle (ACA) configuration and detection of occludable/angle-closure (anterior segment OCT (AS-OCT) may be used for assessment of the anterior chamber angle and as a rapid screening tool for detection of occludable angles; cited studies include Nolan et al. 2007, Pekmezci et al. 2009, Desmond et al. 2022)
4 Active Policies
AMBETTER-CP.VP.43 — External Ocular Photography
AETNA-CPB-0749 — Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging
A57068 — Billing and Coding: Ocular Photography - External
L34393 — Ocular Photography - External
Related Codes
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