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ICD-10-CM N28.85, Pyeloureteritis cystica | No Prior Auth

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`N28.85`, Pyeloureteritis cystica

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.

Key Coverage Criteria

Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).

1 Active Policy

A55336, Billing and Coding: Retroperitoneal Ultrasound

Related Codes

76775(1 policies)76776(1 policies)B25.2(1 policies)B52.0(1 policies)C25.0(1 policies)C25.1(1 policies)C25.2(1 policies)76770(1 policies)

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