H35.349 — Macular cyst, hole, or pseudohole, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation supporting MAC must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- When G9 modifier is used for history of severe cardiopulmonary disease, document the clinical decision-making process and the need for additional monitoring in the medical record.
Key Coverage Criteria
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
- 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.
6 Active Policies
A57637 — Billing and Coding: Visual Field Examination
J09
L33766 — Visual Field Examination
J09
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
AETNA-CPB-0293 — Corneal Graft and Amniotic Membrane Transplantation, Corneal Stromal Lenticule Transplantation, Limbal Stem Cell Transplantation, or Sural Nerve Grafting for Ocular Indications
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.