Does M25.531 require prior authorization?

No, M25.531 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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`M25.531`, Pain in right wrist

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 contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM codes that reflect the patient's condition and the reason for the service; claims without ICD-10-CM codes will be returned.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A permanent record of the ultrasound and its interpretation must be kept in the patient's record, including images labeled with exam date, patient identification, and image orientation; documentation of variations from normal with measurements; and a formal interpretation.

Key Coverage Criteria

Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.

20 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

WPS-J5-L34645, Urine Drug Testing

A56915, Billing and Coding: Urine Drug Testing

A59553, Billing and Coding: Trigger Point Injections

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M25.531, Pain in right wrist