S05.51XS — Penetrating wound with foreign body of right eyeball, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Document general ophthalmoscopy and biomicroscopy findings in the medical record even when these services are included in extended ophthalmoscopy and not separately billed.
- For extended ophthalmoscopy, include a drawing or equivalent documentation that demonstrates the extended nature of the exam to support separate payment.
- Orders for CPT 92227 and CPT 92228 must be from the treating physician or other treating practitioner acting within the scope of license and Medicare requirements and this order must be documented in the record.
- When extended ophthalmoscopy is performed during a global surgery period and is unrelated to the surgical condition, document the unrelatedness and report modifier -76 or -79 as appropriate.
Key Coverage Criteria
- Extended ophthalmoscopy (CPT 92201, 92202) is payable when documented as an extended ophthalmoscopy that meets indicated standards (e.g., includes a retinal drawing or equivalent documentation) beyond a general ophthalmologic exam.
- Fundus photography (CPT 92227, CPT 92228) is covered when ordered by the treating physician or other treating practitioner acting within the scope of his/her license and Medicare requirements.
- CPT 92227 is covered when used to evaluate asymptomatic patients at risk with known disease likely to cause retinal disease (e.g., diabetes mellitus) when ordered by the treating physician.
- CPT 92228 is a covered service when ordered by the treating physician or other treating practitioner acting within the scope of license and Medicare requirements.
- CPT 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
- CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.
20 Active Policies
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
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
A56537 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
Related Codes
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