S05.40XA — Penetrating wound of orbit with or without foreign body, unspecified eye, initial 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.
- Medical records must document the indication(s) supporting use of IVIG for each claim.
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.
- IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
- Posterior segment OCT is reasonable and necessary to diagnose and manage retinal and neuro-ophthalmic diseases involving the optic nerve, subretinal and intraretinal abnormalities, vitreoretinal relationships, or retinal nerve fiber layer changes.
- Posterior segment OCT is reasonable and necessary to diagnose early glaucoma and to monitor glaucoma treatment.
- Posterior segment OCT may be used to differentiate causes of optic nerve disorders when the diagnosis is uncertain.
- Posterior segment OCT may be used to diagnose or manage the patient when visual field results are insufficient or reliable visual field testing cannot be performed due to visual, physical, mental, or age-related constraints.
5 Active Policies
A57554 — Billing and Coding: Immune Globulins
J05
L34771 — Immune Globulins
J05
A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
ANTHEM-CG-SURG-03
Related Codes
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