Does I97.131 require prior authorization?

No, I97.131 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`I97.131`, Postprocedural heart failure following other surgery

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (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).
Transesophageal echocardiography (TEE) is indicated when transthoracic echocardiography (TTE) provides inadequate visualization of cardiac anatomy for structures normally visualized by TTE; report ICD-10-CM R93.1 or R93.8 as the primary diagnosis and the cardiac abnormality as a secondary diagnosis.
TEE is indicated when performed during an open chest (intraoperative) procedure; report ICD-10-CM Z01.89 as the primary diagnosis and the reason for the surgical procedure as the secondary diagnosis.
Use CPT 93315, 93316, or 93317 for evaluation of congenital cardiac anomalies (these codes are reserved for congenital anomalies only).

20 Active Policies

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

A52850, Billing and Coding: Cardiac Catheterization and Coronary Angiography

NGS-J6-L33557, Cardiac Catheterization and Coronary Angiography

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

NGS-J6-L33579, Transesophageal Echocardiography (TEE)

A52868, Billing and Coding: Transesophageal Echocardiography (TEE)

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

NOVITAS-JH-L35016, Transesophageal Echocardiography (TEE)

NGS-JK-L33579, Transesophageal Echocardiography (TEE)

NGS-JK-L33577, Transthoracic Echocardiography (TTE)

NGS-JK-L33557, Cardiac Catheterization and Coronary Angiography

A56505, Billing and Coding: Transesophageal Echocardiography (TEE)

NOVITAS-JL-L35016, Transesophageal Echocardiography (TEE)

A53988, Billing and Coding: Percutaneous Ventricular Assist Device

A56476, Billing and Coding: Cardiac Radionuclide Imaging

`I97.131`, Postprocedural heart failure following other surgery

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

I97.131, Postprocedural heart failure following other surgery

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`I97.131`, Postprocedural heart failure following other surgery