H57.9 — Unspecified disorder of eye and adnexa
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient medical record must include the ordering provider's assessment related to the patient's complaint for that visit, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For diagnostic tests, report the test result on the claim if known; if result is not known, report the symptoms that prompted the test.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- Advance Beneficiary Notice (ABN) requirements: Form CMS-R-131 must be signed by the beneficiary when applicable; for Part A MAC claims, occurrence code 32 and the date of the ABN must be submitted.
Key Coverage Criteria
- CPT 66982 (complex cataract extraction) is covered when the procedure requires devices or techniques not generally used in routine cataract surgery.
- For diagnoses H20.21-H20.23, H21.261-H21.263, H21.29, or H21.561-H21.563, CPT 66982 may be billed if the operative note documents use of an endocapsular ring to partially occlude the pupil.
- For diagnoses H21.271-H21.273, H26.211-H26.213, or H26.221-H26.223, CPT 66982 may be billed if the operative note documents micro iris hooks inserted through four separate corneal incisions, a Beehler or similar expansion device, synechialysis with papillary stretch maneuvers, multiple sphincterotomies with scissors, or sector iridotomy with suture repair of the iris sphincter.
- For diagnoses H21.221-H21.223, CPT 66982 may be billed if the operative note documents use of a permanent intraocular suture or a capsular support ring to place the intraocular lens in a stable position.
- For diagnoses H21.531-H21.533, CPT 66982 may be billed if the operative note documents employment of a capsular support ring or an endocapsular support ring for partial occlusion of the pupil.
- For the broad set of diagnoses including H21.81, H21.89, H21.9, H22, H25.x, H26.x, E08.36-E13.36, and Q13.0/Q13.2, CPT 66982 may be billed if the operative note documents interventions such as micro iris hooks (four incisions), Beechler-type expansion devices, synechialysis with papillary stretch, multiple sphincterotomies, sector iridotomy with suture repair, permanent intraocular sutures, capsular support rings, or endocapsular rings as noted in the operative report.
7 Active Policies
A59805 — Billing and Coding: Cataract Surgery
J05
L39905 — Cataract Surgery
J05
L33558 — Cataract Extraction
J06
A56544 — Billing and Coding: Cataract Extraction
J06
A56453 — Billing and Coding: Cataract Extraction
Related Codes
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