H22, Disorders of iris and ciliary body in diseases classified elsewhere
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.
- The medical record must document relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures sufficient to support medical necessity for the cataract extraction.
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.
- Cataract extraction is covered when necessary to provide an unimpeded view of the fundus to allow proper management of posterior segment disease, with the cataract diagnosis billed as primary and the posterior segment disease as secondary.
- Cataract extraction is covered for anisometropia when there is significant aniseikonia secondary to a prior cataract extraction with IOL implant and the aniseikonia is visually significant to the patient.
- Complex cataract extraction (CPT 66982 and 66987) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery (e.g., capsular support devices, permanent intraocular sutures, extensive iris maneuvers, prosthetic iris placement, primary posterior capsulorhexis, treatment of phacolytic glaucoma, or other extraordinary operative/postoperative work).
- Cataract extraction is covered when the physician performing the preoperative ophthalmologic evaluation lists cataract as the primary diagnosis (ICD-10-CM codes per LCD L35091).
- Preoperative evaluation and management (E/M) services are covered when the evaluating clinician documents cataract as the primary or secondary diagnosis when medically necessary.
20 Active Policies
CGS-L34393, Ocular Photography - External
J15
CGS-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J15
CGS-L37578, Micro-Invasive Glaucoma Surgery (MIGS)
J15
CGS-L33954, Cataract Extraction
J15
A57483
Related Codes
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