H40.1194 — Primary open-angle glaucoma, unspecified eye, indeterminate stage
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- Medical record documentation by the ordering/referring physician must state the clinical indication/medical necessity for the test and include the test results.
- If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy test results and interpretation plus copies of the ordering/referring physician's order.
- Documentation should contain a history and physical (H&P) supporting the diagnosis for which the corneal pachymetry is being rendered.
Key Coverage Criteria
- Corneal pachymetry (measurement of corneal thickness) is covered to evaluate patients with a diagnosis of increased intraocular pressure.
- Repeat corneal pachymetry is covered after interval corneal trauma or corneal surgery to reassess corneal thickness.
- Corneal pachymetry is generally covered when performed as indicated by current medical literature or accepted standards of practice for clinical management.
- Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
- Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
- Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.
14 Active Policies
A56548 — Billing and Coding: Corneal Pachymetry
J06
L33574 — Visual Fields Testing
J06
L33630 — Corneal Pachymetry
J06
L33567 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
A56726 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.