S05.20XD — Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- This policy provides billing, coding, and guideline information that complements the Local Coverage Determination (LCD) 'Cosmetic and Reconstructive Surgery' L33428; the full policy content is not included here, so specific documentation requirements (e.g., medical records, prior authorizations, forms) are not available in the provided excerpt.
Key Coverage Criteria
- Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
- Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
- Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
- Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.
- Conditions including tuberculosis of eye (A18.53, A18.54), diabetes mellitus with ophthalmic complications (E08.311-E08.359, E09.311-E09.359, E10.311-E10.359, E11.311-E11.359, E13.311-E13.359), ophthalmia nodosa (H16.241-H16.249), selected anterior segment disorders (H20.00-H21.1X1), and transient cerebral ischemic attacks with ocular involvement (G45.3) may require extended ophthalmoscopy and are covered.
- Malignant and secondary neoplasms of the eye and adnexa (C69.20-C69.42, C79.89-C79.9) and benign neoplasms of the eye and adnexa (D31.20-D31.32) may require and are covered for extended ophthalmoscopy.
6 Active Policies
A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
A56726 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
L33567 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
Related Codes
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