Does R10.9 require prior authorization?

No, R10.9 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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`R10.9`, Unspecified abdominal pain

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

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 services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.

Key Coverage Criteria

Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
This article does not specify clinical indications; refer to LCD L36427 for covered indications for wireless capsule endoscopy.
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).

20 Active Policies

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J18

NGS-J6-L36850, Peripheral Nerve Blocks

A57452, Billing and Coding: Peripheral Nerve Blocks

FIRST_COAST-L33933

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R10.9, Unspecified abdominal pain