H21.40 — Pupillary membranes, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information such as complete name and dates of service.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
Key Coverage Criteria
- Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
- Visual field examination is covered for patients with inflammation or disorders of the eyelids that may affect the visual field.
- Visual field examination is covered for patients with a documented diagnosis of glaucoma.
- Visual field examination is covered for glaucoma suspects, defined by increased intraocular pressure, inter-eye intraocular pressure asymmetry greater than 2–3 mm Hg, or optic nerve findings suspicious for glaucoma (asymmetric cupping, disc hemorrhage, absent or thinned temporal rim).
- Visual field examination is covered for patients with a documented disorder of the optic nerve, neurologic visual pathway, or retina.
- Visual field examination is covered for patients with a recent intracranial hemorrhage, intracranial mass, or recent measurement of increased intracranial pressure, with or without visual symptoms.
3 Active Policies
A57637 — Billing and Coding: Visual Field Examination
J09
L33766 — Visual Field Examination
J09
AETNA-CPB-0354 — YAG Laser in Ophthalmology and Other Selected Indications
Related Codes
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