Does K57.13 require prior authorization?

No, K57.13 does not require prior authorization (high confidence). Covered without prior authorization.

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`K57.13`, Diverticulitis of small intestine without perforation or abscess with bleeding

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
The patient's medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.

For Patency Capsule Testing submitted for denial purposes, enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or the electronic equivalent) and use CPT 91299; the ingestion is part of the test.

For Part A inpatient hospital claims, report the principal diagnosis in UB-04 FL 67, the admitting diagnosis in FL 69, and up to eight additional diagnoses in FLs 67A-67Q; for outpatient hospital claims, report the diagnosis in FL 67 or a symptom if no definitive diagnosis, and use Z00.00-Z13.9 if no referring diagnosis is available.

For Part B claims, the place of service code used by the physician and suppliers should reflect the location where the beneficiary received the technical component of the service.

Key Coverage Criteria

Capsule endoscopy (CPT 91110, 91111 global) is payable under Medicare Part B when performed in office (POS 11), independent diagnostic testing facility (POS 49), or independent clinic (POS 49).
Technical component codes 91110-TC and 91111-TC are payable under Part B in office (11), IDTF (49), independent clinic (49), federally qualified health center (50), and rural health clinic (72).
Professional component codes 91110-26 and 91111-26 are payable under Part B in office (11), outpatient hospital (19 and 22), inpatient hospital (21), independent clinic (49), and public health clinic (71).
When capsule endoscopy is normal but compelling symptoms persist, irritable bowel syndrome or abdominal pain diagnosis codes K58.0, K58.9, R10.11-R10.13, R10.2, R10.31-R10.33, or R10.84 are on the list of covered diagnoses and may be used.
Report Patency Capsule Testing using CPT 91299 and enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or electronic equivalent); the ingestion of the capsule is part of the test.
Telemetric gastrointestinal capsule imaging includes a technical component (capsule provision, hookup, downloading/processing) and a professional component (image review and interpretation with report); report the technical component's place of service as the location where the image download to the computer is performed.

12 Active Policies

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J18-L34081, Endoscopy by Capsule

J18

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L33774, Wireless Capsule Endoscopy

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A56704, Billing and Coding: Wireless Capsule Endoscopy

NOVITAS-JH-L35089, Wireless Capsule Endoscopy

A57753, Billing and Coding: Wireless Capsule Endoscopy

NOVITAS-JL-L35089, Wireless Capsule Endoscopy

A56461, Billing and Coding: Endoscopy by Capsule

A56421, Billing and Coding: CT of the Abdomen and Pelvis

AETNA-CPB-0396, Gastrointestinal Function: Selected Tests

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K57.13, Diverticulitis of small intestine without perforation or abscess with bleeding