T85.21XA — Breakdown (mechanical) of intraocular lens, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must include the ordering/provider assessment related to the patient's complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For Group 2 ICD-10-CM and Group 2 CPT codes, documentation must include visual field results and/or photographs supporting functional impairment.
- For induction of visually compromising dermatochalasis by ptosis repair with large levator aponeurosis dehiscence, documentation must show the dehiscence and an operative note indicating skin excess after ptosis repair and necessity of blepharoplasty.
- When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI; diagnostic test claims should report the test result or the symptoms prompting the test if the result is unknown.
Key Coverage Criteria
- Blepharoplasty is covered when medical necessity is documented in the medical record, including relevant history, physical exam, and diagnostic test results that support the procedure per the applicable LCD.
- For Group 2 ICD-10-CM/CPT codes, coverage requires documentation of visual field testing results and/or photographs demonstrating functional visual impairment from eyelid pathology.
- Blepharoplasty may be covered when visually compromising dermatochalasis is induced by ptosis repair in patients with large levator aponeurosis dehiscence if documentation shows the dehiscence and an operative note documents residual skin excess after ptosis repair that makes blepharoplasty necessary.
- Posterior capsular opacification (ACO/PCO) after cataract surgery causing significant visual debility is an indication for capsulotomy (YAG laser or discission).
- Capsulotomy performed less than 3 months after cataract surgery is covered only when documented indications exist (examples: preoperative uveitis, chronic glaucoma, diabetes mellitus, prolonged pilocarpine use, or significant visual debility).
- Repeat capsulotomy on the same eye (during the same or separate episode of care) is covered if the medical record contains a clear rationale and documented indications for the repeat procedure.
20 Active Policies
A56916 — Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J05
L34760 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J05
L33621 — Ophthalmic Biometry for Intraocular Lens Power Calculation
J06
L34380 — Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
J06
Related Codes
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