Does R10.816 require prior authorization?

No, R10.816 does not require prior authorization (high confidence). Covered without prior authorization.

`R10.816`, Epigastric abdominal tenderness

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
When billed outside the specified POS, the test is covered if ordered by a diagnosing/treating specialist in Infectious Diseases, Gastroenterology, Oncology, or Transplant, with specialist communication documented in the medical record.
Multiplex GPP tests for diagnosis of acute gastroenteritis (AGE) are covered when billed in POS 20, 21, 22, 23, or 81.
Multiplex GPP tests are covered when ordered as part of a pre-transplant evaluation for an immunocompromised beneficiary and billed in POS 81 (Independent Laboratory).
An access-based exception may permit coverage for tests ordered by non-specialists outside the specified POS when the beneficiary cannot reasonably reach a specialist (e.g., rural or island locations) and the ordering provider is closer to the beneficiary; this must be documented.
Community-acquired acute diarrhea defined as ≥3 loose or watery stools per day for ≤14 days with duration >7 days.

NGS-J6-L39226, Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

A58963, Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

Ask Backwork about documentation requirements, denial risks, or coverage in your state.