Does I31.31 require prior authorization?

Yes, I31.31 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

Backwork Sign up free

`I31.31`, Malignant pericardial effusion in diseases classified elsewhere

ICD-10-CM

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation Required

The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.

Key Coverage Criteria

Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
Cardiac CT (CCT) or Coronary CT Angiography (CCTA) is covered when the patient's medical record documents medical necessity consistent with the indications and limitations set forth in the attached Local Coverage Determination (LCD).
Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.

20 Active Policies

CGS-J15-L33947, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L33947, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

J18

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

WPS-J5-L39913, Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)

A57552, Billing and Coding: Coronary Computed Tomography Angiography (CCTA)

WPS-J5-L35121, Coronary Computed Tomography Angiography (CCTA)

WPS-J5-L35490, Category III Codes

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

A56737, Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

A52850, Billing and Coding: Cardiac Catheterization and Coronary Angiography

NGS-J6-L33557, Cardiac Catheterization and Coronary Angiography

NGS-J6-L33559, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

WPS-J8-L35121, Coronary Computed Tomography Angiography (CCTA)

WPS-J8-L39913, Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)

WPS-J8-L35490, Category III Codes

FIRST_COAST-L33756, Transesophageal Echocardiogram

`I31.31`, Malignant pericardial effusion in diseases classified elsewhere

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

I31.31, Malignant pericardial effusion in diseases classified elsewhere

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`I31.31`, Malignant pericardial effusion in diseases classified elsewhere