H36.819 — Nonproliferative sickle-cell retinopathy, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Explicit clinical documentation is required to justify any treatment frequency that is more frequent than approximately every 4 weeks in a given eye.
- For Part B claims, enter 'Intravitreal bevacizumab, [dose] mg' in Item 19 of the CMS-1500 or in Loop 2300/2400 NTE01 (NTE, 02) for electronic claims.
- When billing J7999, enter '1' in the days/units field for one eye or '2' if both eyes are treated in the same encounter.
- When billing CPT 67028, use modifier RT or LT to indicate the eye treated; if billing bilateral use modifier 50.
Key Coverage Criteria
- When intravitreal bevacizumab is acquired from a compounding source or compounded in the physician's facility/office, bill using HCPCS J7999 on claims.
- HCPCS J7999 shall be used for all compounded injectable drugs (not restricted to bevacizumab).
- For Part A claims for intravitreal compounded bevacizumab, bill using HCPCS C9257 and provide the number of units.
- Use scanning computerized ophthalmic diagnostic imaging (CPT 92134) at 4–6 week intervals when appropriate to evaluate need for re-treatment.
2 Active Policies
A53009 — Billing and Coding: Intraocular Bevacizumab
A53008 — Billing and Coding: Intraocular Bevacizumab
Related Codes
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