Does A52.00 require prior authorization?

No, A52.00 does not require prior authorization (high confidence). Covered without prior authorization.

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`A52.00`, Cardiovascular syphilis, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When a limited or follow-up echocardiogram is performed, document the targeted cardiac problem/region and bill using the appropriate CPT code (93308 or 93321).
If the study is a screening exam, document and bill with the appropriate screening ICD-10 code; document any abnormal findings and use the resulting diagnosis for subsequent billing when applicable.
Document use of ultrasound contrast enhancement and its supplies separately when billed, and do not submit separate claims for diagnostic injection services integral to the contrast procedure.
Follow the Local Coverage Determination L37379 and include documentation sufficient to support medical necessity when multiple imaging studies are billed.

Key Coverage Criteria

Follow-up or limited transthoracic echocardiography performed to evaluate a single specified cardiac problem or region must be billed with CPT 93308.
Limited Doppler/follow-up echocardiographic studies (for targeted velocity or gradient assessment) should be billed with CPT 93321 (e.g., tricuspid regurgitant velocity to estimate pulmonary artery systolic pressure or sequential transmitral velocity in mitral stenosis).
Non-stress transthoracic echocardiography (TTE) in adults (age 18 and older) considered medically necessary when consistent with ACC Appropriate Use Criteria (AUC) 'Appropriate Care' category (scores 7-9) for: Multimodality Imaging in Cardiovascular Evaluation of Patients Undergoing Nonemergent, Noncardiac Surgery (ACC/Doherty, et al., 2024); Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease (Sachdeva, et al., 2020); Multimodality Imaging in the Assessment [...]
Non-stress TTE considered medically necessary when consistent with ACC/AHA Guidelines (Class I and/or IIa) including: Guideline for the Diagnosis and Management of Hypertrophic Cardiomyopathy (Ommen, et al., 2024); Guideline for the Diagnosis and Management of Atrial Fibrillation (Joglar, et al., 2023); Guideline for the Diagnosis and Management of Aortic Disease (2022); Guideline for the Management of Heart Failure (Heidenreich, et al., 2022); Guideline for the Evaluation and Diagnosis of Chest [...]
Non-stress TTE (with or without 3D; with contrast as needed) is considered medically necessary for the following specific clinical scenarios: Multisystem Inflammatory Syndrome (MIS) associated with SARS-CoV-2 (COVID-19) infection; individual taking FINTEPLA® (fenfluramine) for an FDA-approved indication (e.g., Dravet syndrome); individual taking CAMZYOS™ (mavacamten) for an FDA-approved indication (i.e., adult with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy [oHCM]).
A transthoracic echocardiogram may be considered medically necessary when criteria in the applicable policy statements are met and when billed with a diagnosis code from Table 1 (Covered ICD-10-CM Diagnosis codes).

2 Active Policies

CIGNA-0510, Transthoracic Echocardiography in Adults

A56625, Billing and Coding: Echocardiography

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A52.00, Cardiovascular syphilis, unspecified