H25.091 — Other age-related incipient cataract, right eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When billing ICD-10 codes H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, H26.231, H26.232, H26.233, E08.36, E09.36, E10.36, E11.36, E13.36, or H28, the ICD-10 code for the underlying condition must be listed and coded first on the claim.
- When billing ICD-10 codes H26.31, H26.32, H26.33, or H26.8, the causative agent must be identified on the claim.
- All documentation must be maintained in the patient's medical record, be legible, include patient identification (e.g., full name, dates of service), and be available to the contractor upon request.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
Key Coverage Criteria
- 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.
- Complex cataract extraction is covered when the procedure requires insertion of iris retractors through additional incisions to maintain or improve exposure.
- Complex cataract extraction is covered when mechanical expansion of the pupil is performed using iris hooks.
- Complex cataract extraction is covered when a sector iridectomy is created with subsequent suture repair of the iris sphincter.
- Complex cataract extraction is covered when an intraoperative iris expansion device (e.g., Malyugin ring) is used to maintain pupil dilation.
14 Active Policies
A57637 — Billing and Coding: Visual Field Examination
J09
A58592 — Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)
J09
L38926 — Cataract Extraction (including Complex Cataract Surgery)
J09
L33766 — Visual Field Examination
J09
L35091
Related Codes
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