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ICD-10-CM P04.3, Newborn affected by maternal use of alcohol | No Prior Auth

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`P04.3`, Newborn affected by maternal use of alcohol

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is 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

During excision of left atrial mass;
Evaluation of angina;
Evaluation of aortic diseases;
Evaluation of aortocoronary bypass grafts;
Evaluation of atrial fibrillation/flutter;
ICD-10 I05.0 - I05.9: Diseases of mitral valve

2 Active Policies

AETNA-CPB-0008, Color-Flow Doppler Echocardiography and Myocardial Strain Imaging

A57189, Billing and Coding: Serum Magnesium

Related Codes

Z92.21(2 policies)P03.810(2 policies)Q86.0(2 policies)Z51.11(2 policies)76827(1 policies)76828(1 policies)75561(1 policies)76826(1 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.

Note on Documentation Requirements: Physicians are reminded to bill the findings of the diagnostic test as the primary indication rather than the referring physician’s diagnosis, as indicated by Medicare’s Diagnostic Imaging Billing guidelines.