Z01.01 — Encounter for examination of eyes and vision with abnormal findings
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Document patient age to demonstrate eligibility for screening (e.g., 3 years of age; 4–5 years with inability to cooperate).
- Document evidence of inability to cooperate with routine acuity screening for children 4 to 5 years old when applicable (examples given: intellectual disability, developmental delay, severe behavioral disorders).
- Document that photoscreening was performed (including type of instrument and whether remote or on-site analysis was used) and result (normal/abnormal/unreadable).
- Document referral for a complete eye examination when photoscreening findings are abnormal.
Key Coverage Criteria
- Aetna considers one ocular photoscreening medically necessary for screening all children 3 years of age.
- Aetna considers one ocular photoscreening medically necessary for screening children 4 to 5 years of age who are unable to cooperate with routine acuity screening (e.g., intellectual disability, developmental delay, and severe behavioral disorders).
- CPT codes covered if selection criteria are met: 99174 (Instrument-based ocular screening (eg, photoscreening, automated refraction), bilateral; with remote analysis and report) and 99177 (with on-site analysis).
- ICD-10 codes covered if selection criteria are met (not all-inclusive): H53.001 - H54.8 (Visual disturbances, blindness and low vision).
- ICD-10 codes covered if selection criteria are met (not all-inclusive): P07.00 - P07.32 (Disorders of newborn related to short gestation and low birth weight, not elsewhere classified).
- ICD-10 codes covered if selection criteria are met (not all-inclusive): Z00.129 (Encounter for routine child health examination without abnormal findings).
4 Active Policies
AMBETTER-CP.VP.13 — Preventative (Routine) Eye Examination
AMBETTER-CP.VP.13-Attachment-A-Refractive-Hardware — Preventive (Routine) Eye Examination Attachment A: Refractive Hardware
AETNA-CPB-0689 — Ocular Photoscreening
ANTHEM-CG-MED-35 — CG-MED-35 Retinal Telescreening Systems
Related Codes
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