S02.31XA — Fracture of orbital floor, right side, initial encounter for closed fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
- Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.
- The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.
- All external ocular photographs must be permanently labeled with the patient's name, date, and notation of which eye is pictured, and copies must be available for Medicare review.
Key Coverage Criteria
- No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
- External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.
- External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
- Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
12 Active Policies
AMBETTER-CP.VP.43 — External Ocular Photography
A57215 — Billing and Coding: MRI and CT Scans of the Head and Neck
A59840 — Billing and Coding: Magnetic Resonance Imaging of the Head and Neck
A56612 — Billing and Coding: CT of the Head
A56729 — Billing and Coding: Magnetic Resonance Imaging of the Head and Neck
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.