T76.22XA — Child sexual abuse, suspected, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For fundus photography, the medical record must document relevant medical history, physical examination, pertinent diagnostic test results, retention of the photographs, an interpretation/report, whether the pupil was dilated, and which drug was used; records must be legible and available to the carrier.
- For extended ophthalmoscopy the record must include relevant history, physical exam, pertinent diagnostic results, retinal drawings meeting Appendix A specifications (separate detailed sketch 3-4 inches, labeled, colors preferred), and documentation of the method of examination and pupil dilation/drug; records must be legible and available.
- For a diagnosis of glaucoma (ICD H40.001-H40.152) documentation must include a separate detailed optic nerve drawing with an interpretation that affects treatment, and documentation of cupping, disc rim, pallor, slope, and any surrounding pathology.
Key Coverage Criteria
- 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.
- Other ocular conditions generally requiring monitoring may be covered for extended ophthalmoscopy when documentation supports medical necessity, subject to specified frequency limits.
12 Active Policies
A56726 — Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
A56937 — Billing and Coding: Psychiatry and Psychology Services
J06
L33567 — Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
J06
L33632 — Psychiatry and Psychology Services
J06
Related Codes
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