Does K64.5 require prior authorization?

No, K64.5 does not require prior authorization (high confidence). Covered without prior authorization.

`K64.5`, Perianal venous thrombosis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Supportive clinical documentation evidencing the condition and treatment must be in the clinical notes or procedure note and made available upon request to the MAC or other authorized CMS auditor.
Medical records need not be submitted with the claim unless modifier -22 is used, but must be furnished to Medicare upon request and must support medical reasonableness, necessity, frequency, and substantiate the diagnosis listed on the claim.
The colonoscopy report must document the maximum depth of penetration, a description of any abnormal findings, and any procedures performed as a result of those findings (e.g., biopsy).
For a follow-on CRC screening colonoscopy after a positive stool-based test (effective 2023-01-01), the providing practitioner must apply modifier -KX to confirm the clinical requirements of the Complete CRC Screening policy are met.

A colonoscopy may be billed when a sigmoidoscope is used only if the bowel is sufficiently short that the entire colon can be examined and this fact is clearly documented in the clinical record.
An incomplete colonoscopy (inability to advance the colonoscope to the cecum or colon‑small intestine anastomosis due to unforeseen circumstances) is billed using codes 44388, 45378, G0105 or G0121 with modifier -53.
When the colonoscopy procedure is unusual or difficult, report modifier -22 (unusual procedural services) on the claim.
A follow-on screening colonoscopy after a Medicare-covered non-invasive stool-based CRC screening test that is positive is included in a Complete Colorectal Cancer (CRC) Screening and should be billed as such with modifier -KX to confirm clinical requirements are met.
The most specific ICD-10-CM diagnosis code available must be selected and billed as the line diagnosis linked to the colonoscopy procedure.

A57342, Billing and Coding: Diagnostic and Therapeutic Colonoscopy

Ask Backwork about documentation requirements, denial risks, or coverage in your state.