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ICD-10-CM O12.20, Gestational edema with proteinuria, unspecified trimester | No Prior Auth

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`O12.20`, Gestational edema with proteinuria, unspecified trimester

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical record must reflect how the cystatin C test result was used in the patient's plan of care.
Medical records must be maintained and legible, include complete patient identification and dates of service, and include the legible signature of the responsible physician or non-physician practitioner.
The submitted medical record must support the selected ICD-10-CM code(s) and show medical necessity for the cystatin C test.
The laboratory or billing provider must retain a physician requisition that states the diagnosis/ICD-10-CM code that warrants the test.

Key Coverage Criteria

Cystatin C measurement is covered when medical record documents an adult patient (>=18 years) with a creatinine-based eGFR of 45–59 ml/min/1.73 m2 and no markers of kidney damage.
Cystatin C measurement is covered when the ordering documentation demonstrates that creatinine-based GFR estimates are believed to be inaccurate and more accurate GFR knowledge will affect clinical decision-making or the patient's plan of care.
Determination of gestational age
Assessment of fetal number (e.g., multiple gestation)
Assessment of fetal viability
Determination of placental location

2 Active Policies

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

A57643, Billing and Coding: Lab: Cystatin C Measurement

Related Codes

O12.10(2 policies)76801(1 policies)76817(1 policies)76811(1 policies)76815(1 policies)76816(1 policies)76805(1 policies)76377(1 policies)

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Ordering clinician documentation (e.g., history and physical, exam findings, problems/diagnoses, relevant lab data) must support the decision to perform cystatin C testing, including documentation that creatinine-based eGFR is 45–59 ml/min/1.73 m2 with no markers of kidney damage and the rationale for why creatinine-based estimates are thought inaccurate.

Claims must report CPT code 82610, enter 1 unit of service, and include the appropriate ICD-10-CM diagnosis code; bill type and revenue codes must comply with CMS claims processing guidance.