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ICD-10-CM R36.1, Hematospermia | No Prior Auth

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`R36.1`, Hematospermia

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
Documentation supporting the service must be available to Medicare upon request.
When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI.

Key Coverage Criteria

Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
N98.1: Hyperstimulation of ovaries
N99.83: Residual ovary syndrome
Benign neoplasm and neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct (D35.2 - D35.3; D44.3 - D44.4)
Neoplasm of uncertain behavior of female genital organs (D39.0 - D39.2)
Neoplasm of uncertain behavior of other and unspecified male genital organs (D40.8 - D40.9)

5 Active Policies

NGS-J6-L33578, Transrectal Ultrasound

J6

A57427, Billing and Coding: Transrectal Ultrasound

J6

NGS-JK-L33578, Transrectal Ultrasound

JK

ANTHEM-CG-RAD-28, Transrectal Ultrasonography

AETNA-CPB-0327, Infertility

Related Codes

N46.01(5 policies)D07.5(4 policies)76872(4 policies)C78.5(4 policies)D01.1(4 policies)D01.3(4 policies)C21.8(4 policies)C79.82(4 policies)

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Refills based upon documentation in cycle sheets.

Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be required.