Does R31.0 require prior authorization?

No, R31.0 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`R31.0`, Gross hematuria

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

Claims must include the appropriate CPT code (88120 or 88121), 1 unit of service, and an appropriate ICD-10 diagnosis code for the clinical indication.
Laboratories reporting only the technical component should append the TC modifier to CPT 88120 or 88121.
Billing entities must be CLIA certified to submit UroVysion claims and should maintain CLIA certification documentation in the medical record/claims file.
To bill a professional component, the physician must personally read, quantitate, and interpret the probe-stained cells/tissues and document that interpretive work in the medical record.

Key Coverage Criteria

FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered when performed on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder cancer using urine specimens.
Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
FISH bladder tumor marker testing (CPT 88120 or 88121) is covered when performed using validated assays (e.g., UroVysion) on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis.
FISH bladder tumor marker testing (CPT 88120 or 88121) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder (urothelial) carcinoma.

20 Active Policies

CGS-J15-L36975, Bladder/Urothelial Tumor Markers

J15

CGS-J18-L36975, Bladder/Urothelial Tumor Markers

J18

A57056, Billing and Coding: Aortography and Peripheral Angiography

A57636, Billing and Coding: Duplex Scanning

FIRST_COAST-L33674

Have a follow-up question?

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

Ask Backwork about R31.0 Sign up free

R31.0, Gross hematuria