Does R31.9 require prior authorization?

No, R31.9 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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`R31.9`, Hematuria, unspecified

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

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
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.

Key Coverage Criteria

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).
Duplex scanning is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33674.
Cystatin C measurement is covered when medical record documents an adult patient (>=18 years) with a creatinine-based eGFR of 45–59 ml/min/1.73 m2 and no markers of kidney damage.
Cystatin C measurement is covered when the ordering documentation demonstrates that creatinine-based GFR estimates are believed to be inaccurate and more accurate GFR knowledge will affect clinical decision-making or the patient's plan of care.
Report UroVysion Bladder Kit services using CPT 88120 or 88121 when ordered for a patient with an established diagnosis of cancer or a substantiated suspicion of cancer and when test results will directly impact patient management.

15 Active Policies

A57636, Billing and Coding: Duplex Scanning

FIRST_COAST-L39367, Genetic Testing in Oncology: Specific Tests

FIRST_COAST-L33674, Duplex Scanning

A59123, Billing and Coding: Genetic Testing in Oncology: Specific Tests

NOVITAS-JH-L39365

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R31.9, Hematuria, unspecified