Z96.1 — Presence of intraocular lens
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The diagnosis code that justifies medical need must be included on the claim for refractive lenses and related items.
- Final Rule 1713 items require a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes; claims lacking face-to-face and WOPD per the LCD will be denied and items delivered before receipt of a WOPD will be denied.
- For anti-reflective coating (V2750), tints (V2744,V2745), oversized lenses (V2780), and polycarbonate/Trivex (V2784) when used for medical necessity (and V2784 for monocular vision), the KX modifier must be added and supporting medical necessity documentation must be available upon request; if criteria are not met the GA or GZ modifier must be used (GA if a valid ABN is on file, GZ if not).
- Claim lines for anti-reflective coating, tints, oversized lenses or polycarbonate/Trivex billed without a KX, GA or GZ modifier will be rejected as missing information.
Key Coverage Criteria
- Refractive lenses are covered when used to restore vision normally provided by the natural lens in individuals who lack the organic lens because of surgical removal or congenital absence.
- Coverage of refractive lenses applies even if the surgical removal of the natural lens occurred before Medicare entitlement.
- Ophthalmic biometry using CPT 76519 (A-scan) or CPT 92136 (optical coherence biometry) is payable under Medicare Part B when performed for intraocular lens (IOL) power calculation.
- The global service (76519 or 92136 global) is payable in the office (place of service 11) and independent clinic (49).
- The technical component (TC) of CPT 76519 or 92136 is payable in the office (11), independent clinic (49), federally qualified health center (50), and rural health clinic (72).
- The professional component (26) of CPT 76519 is payable in office (11), off-campus outpatient hospital (19), inpatient hospital (21), on-campus outpatient hospital (22), ambulatory surgical center (24), and independent clinic (49).
6 Active Policies
A52499 — Refractive Lenses - Policy Article
J19
AMBETTER-CP.VP.06 — Medically Necessary Optical Hardware
CIGNA-0125 — Intraocular Lens Implant - (0125)
ANTHEM-CG-SURG-77 — CG-SURG-77 Refractive Surgery
A57070 — Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation
Related Codes
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