Does R09.81 require prior authorization?

No, R09.81 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`R09.81`, Nasal congestion

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
Diagnostic test claims should include the test result if known; if result is not available, report the symptoms that prompted the test.
The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
When using an Advance Beneficiary Notice of Non‑coverage (ABN) with modifier GA, the ABN Form CMS‑R‑131 must be signed by the beneficiary (or properly witnessed if refused) and Part A MAC claims require occurrence code 32 plus the ABN date.

Key Coverage Criteria

CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.
Flow cytometry interpretation is reported using CPT codes 88187–88189 (one interpretation code per specimen).
Quantitative cell counts by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361, and 86367.
Flow cytometry services are payable under Medicare Part B at specified places of service according to CPT: groups of CPTs have defined allowable POS (see mapping in policy).
No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.

20 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

CGS-J18-L34037

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R09.81, Nasal congestion