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ICD-10-CM O12.23, Gestational edema with proteinuria, third trimester | No Prior Auth

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`O12.23`, Gestational edema with proteinuria, third trimester

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must document the medical necessity of the serum magnesium test, including the signs, symptoms, and/or diagnosis that prompted the test.
Laboratories must maintain the physician's order for the serum magnesium test in their records.
Medical records must contain the serum magnesium lab test results.
When requesting individual consideration through written redetermination, providers must include all relevant medical records and supporting literature.

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.

2 Active Policies

A57189, Billing and Coding: Serum Magnesium

A57643, Billing and Coding: Lab: Cystatin C Measurement

Related Codes

N06.5(2 policies)N06.8(2 policies)N06.3(2 policies)N06.4(2 policies)N06.6(2 policies)N06.7(2 policies)N06.0(2 policies)N17.0(2 policies)

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For redetermination, providers must submit at minimum two (2) Phase II studies or one (1) Phase III study to support the request.

Medical record must reflect how the cystatin C test result was used in the patient's plan of care.