Does S04.011A require prior authorization?

No, S04.011A does not require prior authorization (high confidence). Code is covered without prior authorization.

`S04.011A` — Injury of optic nerve, right eye, initial encounter

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

When NCSs and NEMG are performed on the same day for the same patient they must be reported on the same claim.
When billing non-covered services/tests report unlisted neurological CPT 95999 and provide a description of the service/test in block 80 (Part A) or box 19 (Part B) or electronic equivalent; failure to include this information will result in Part A claims being returned and Part B claims rejected.
All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and include the legible signature of the responsible physician or non-physician practitioner.
The submitted medical record must support the selected ICD-10-CM code(s), the submitted CPT/HCPCS code must describe the service performed, and the record must clearly document the medical necessity, the indication for ordering the test(s), and a clear diagnostic impression.

Nerve conduction studies (NCS) without needle electromyography (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the diagnosis codes G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53 is reported.
NCS without NEMG is allowed for individuals with significant lymphedema in the affected extremity when diagnosis code I89.0 is reported in addition to the primary diagnosis.
NCS without NEMG is allowed for individuals treated with anticoagulants when diagnosis code Z79.01 or Z79.02 is reported in addition to the primary diagnosis.
Coverage for electroretinography (ERG) is determined by Local Coverage Determination (LCD) L37371; ERG is covered only when reasonable and necessary per LCD L37371.
Neurophysiology Evoked Potentials (NEPs) — including Somatosensory Evoked Potentials (SEPs), Brainstem Auditory Evoked Potentials (BAEPs/BAERs), and Visual Evoked Potentials (VEPs/VERs) — are covered when determined to be reasonable and necessary in accordance with LCD L34975.
Nerve conduction studies (NCS) without needle EMG (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following ICD-10-CM codes is reported: G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53.

L37015 — Visual Electrophysiology Testing

J05

L34615 — Visual Fields

J05

A57599 — Billing and Coding: Visual Electrophysiology Testing

J05

A57483 — Billing and Coding: Visual Fields

J05

L36831 — Visual Electrophysiology Testing

Ask Verity about documentation requirements, denial risks, or coverage in your state.