Does K68.9 require prior authorization?

No, K68.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`K68.9`, Other disorders of retroperitoneum

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.
Standard bowel cleansing preparations (pre-procedure cathartic regimen) are required prior to virtual colonoscopy / CT colonography.
During the procedure a rectal tube is inserted and the colon is distended using room air or carbon dioxide; images are then taken by a helical CT scanner.
For dedicated imaging of the stomach (virtual upper endoscopy), an oral contrast agent (e.g., water) is administered to opacify and distend the stomach and an intravenous contrast agent is used (e.g., Omnipaque 350) for complete evaluation.

Key Coverage Criteria

Preventive screening: Virtual colonoscopy using computed tomography (CT colonography) performed every 5 years is medically necessary as a preventive service for colorectal cancer screening of average-risk asymptomatic persons 45 years of age or older.
Diagnostic CT colonography (virtual colonoscopy) is medically necessary for colonic evaluation of symptomatic members with a known colonic obstruction when standard optical colonoscopy is contraindicated.
Diagnostic CT colonography is medically necessary for colonic evaluation of symptomatic members with an incomplete colonoscopy (e.g., due to diverticulosis, obstructive or stenosing colonic lesions, or redundant colon).
CPT/HCPCS/ICD-10 code-based coverage (covered if selection criteria are met): CT colonography diagnostic CPTs 74261, 74262; CT colonography screening CPT 74263.
ICD-10 diagnosis codes listed as 'covered if selection criteria are met' for diagnostic CT colonography include K56.50 - K56.52 (Intestinal adhesions with obstruction), K56.600 - K56.699 (Other and unspecified intestinal obstruction), K57.00 - K57.93 (Diverticular disease of intestine), Q42.0 - Q42.9 (Congenital absence, atresia and stenosis of large intestine), T41.0X5+, T41.1x5+, T41.205+, T41.295+, T41.3X5+, T41.45x+, T88.59x+ (Adverse effect of anesthetics), Z79.01 (Long term use of anticoag [...]
ICD-10 diagnosis codes listed as 'covered if selection criteria are met' for screening CT colonography include T41.0X5+, T41.1x5+, T41.205+, T41.295+, T41.3X5+, T41.45x+, T88.59x+ (Adverse effect of anesthetics), Z00.00 - Z00.01 (Encounter for general adult medical examination without/with abnormal findings), Z12.10 - Z12.12 (Encounter for screening for malignant neoplasm of intestinal tract, colon, rectum), Z79.01 (Long-term use of anticoagulants), Z88.4 (Allergy status to anesthetic agent).

3 Active Policies

ANTHEM-CG-LAB-29, Gamma Glutamyl Transferase Testing

AETNA-CPB-0535, Virtual Gastrointestinal Endoscopy

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

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K68.9, Other disorders of retroperitoneum