S05.51XD — Penetrating wound with foreign body of right eyeball, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient’s medical record must include the ordering provider’s assessment as it relates to the patient’s complaint for that visit.
- Medical records must contain relevant medical history and results of pertinent tests or procedures performed.
- For diagnostic tests, report the result of the test if known; otherwise report the symptoms that prompted performing the test.
- All services ordered or rendered to Medicare beneficiaries must be signed and dated; include a signed and dated office visit record or operative report in the medical record.
Key Coverage Criteria
- A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
- When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.
- Coverage for electroretinography (ERG) is determined by Local Coverage Determination (LCD) L37371; ERG is covered only when reasonable and necessary per LCD L37371.
- 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.
20 Active Policies
L33567 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
A56726 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.