Does N13.721 require prior authorization?

No, N13.721 does not require prior authorization (high confidence). Covered without prior authorization.

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`N13.721`, Vesicoureteral-reflux with reflux nephropathy without hydroureter, unilateral

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 medical record must document the ordering provider's assessment related to the visit complaint, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that support medical necessity.
Diagnostic test results should be reported on the claim if known; if results are not available, report the symptoms prompting the test.

For services requiring a referring/ordering physician, the claim must include the referring/ordering physician's name and NPI; for Part A MAC claims using GA modifier, occurrence code 32 and the ABN date are required and ABN Form CMS-R-131 should be signed when applicable.

All office visit records and operative reports must be signed and dated; documentation must be available to Medicare upon request to support services included in the LCD.

Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and the reason(s) the urodynamic service was performed.

Key Coverage Criteria

Cystometrogram (CPT 51725, 51726) is covered when performed to evaluate detrusor contractions, abnormalities of bladder compliance, measure post-void residual, determine bladder capacity, or detect detrusor sphincter dyssynergia (DSD).
Uroflowmetry (CPT 51736, 51741) is covered when used to measure urine flow rate to evaluate suspected reduced detrusor function (eg, neurologic lesion), obstructive causes (eg, BPH, cystocele), or increased flow suggesting stress urinary incontinence (SUI) or intrinsic sphincter dysfunction (ISD).
Urethral pressure profile studies (CPT 51727) are covered when other noninvasive tests are inconclusive and the study is needed to rule out severe urethral incompetence or for limited applications such as artificial urinary sphincter evaluation.
Stimulus evoked response testing (CPT 51792) is covered when used to evaluate suspected cauda equina syndrome or other indications where this neurophysiologic test is clinically indicated.
Voiding pressure studies (CPT 51728, 51729) are covered when the patient is able to void and the test is needed to measure detrusor contractility and detect outlet pressure obstruction.
Intra-abdominal voiding pressure measurement (CPT 51797) is covered when used to account for intra-abdominal pressure components in the bladder pressure curve to better evaluate true detrusor function.

7 Active Policies

CGS-J15-L34056, Urodynamics

J15

CGS-J18-L34056, Urodynamics

J18

A57455, Billing and Coding: Urodynamics

NGS-J6-L33576, Urodynamics

NGS-JK-L33576, Urodynamics

A56802, Billing and Coding: Urodynamics

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

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N13.721, Vesicoureteral-reflux with reflux nephropathy without hydroureter, unilateral