H40.242 — Residual stage of angle-closure glaucoma, left eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
- Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
- 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.
Key Coverage Criteria
- Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
- Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
- 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).
20 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
A57483 — Billing and Coding: Visual Fields
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
L39905 — Cataract Surgery
J05
L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Related Codes
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