Q12.0 — Congenital cataract
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Maintain all documentation in the patient’s medical record; every page must be legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
- The submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Speech-language pathology (SLP) services for treatment or evaluation of communication disorders when determined reasonable and necessary per LCD L35070.
- Selection and prescription of speech-generating devices should be billed with CPT code 92607.
- Adaptation and training for speech-generating devices should be billed with CPT code 92609.
- Report group therapy with CPT code 92508 when patients are not receiving direct one-on-one contact and are supervised by the therapist.
- Use the appropriate CPT evaluation code for re-evaluations in SLP because CPT does not define a distinct re-evaluation code.
- 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.
20 Active Policies
A59805 — Billing and Coding: Cataract Surgery
J05
L34615 — Visual Fields
J05
L39905 — Cataract Surgery
J05
A57483 — Billing and Coding: Visual Fields
J05
L33621 — Ophthalmic Biometry for Intraocular Lens Power Calculation
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.