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ICD-10-CM S26.12XA, Laceration of heart without hemopericardium, initial encounter | No Prior Auth

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`S26.12XA`, Laceration of heart without hemopericardium, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of the qualifications of personnel performing TEE should be available upon request.
For diagnostic TEEs, report the test result if known; if not known, report the symptoms that prompted the test.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim.

Maintain copies of image documentation (paper or tape) and include all appropriate measurements; Doppler interrogations must state modes used and provide qualitative and quantitative data.

A covered TEE must include a complete written interpretation/report by the performing physician, and this report must be available upon request.

The medical record must document medical necessity including relevant history, physical exam, results of pertinent diagnostic tests/procedures, and reasons for repeat testing.

Key Coverage Criteria

Transesophageal echocardiography (TEE) is indicated when transthoracic echocardiography (TTE) provides inadequate visualization of cardiac anatomy for structures normally visualized by TTE; report ICD-10-CM R93.1 or R93.8 as the primary diagnosis and the cardiac abnormality as a secondary diagnosis.
TEE is indicated when performed during an open chest (intraoperative) procedure; report ICD-10-CM Z01.89 as the primary diagnosis and the reason for the surgical procedure as the secondary diagnosis.
Use CPT 93315, 93316, or 93317 for evaluation of congenital cardiac anomalies (these codes are reserved for congenital anomalies only).
CPT 93355 is indicated to report TEE services performed during transcatheter intracardiac therapies and includes probe passage, image acquisition/interpretation, intra-procedural manipulation to guide sizing/placement, assessment of adequacy and complications, and final report.
3D imaging (CPT 93319) and CT/MR fusion or related add-on imaging (CPT 76376, 76377) are allowable when billed as add-on services with their listed base TEE imaging codes.
Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

J6

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

J6

A52868, Billing and Coding: Transesophageal Echocardiography (TEE)

J6

NGS-J6-L33579, Transesophageal Echocardiography (TEE)

J6

A57179, Billing and Coding: Transesophageal Echocardiogram

J9

FIRST_COAST-L33756, Transesophageal Echocardiogram

J9

NOVITAS-JH-L35434, Oximetry Services

JH

NGS-JK-L33577, Transthoracic Echocardiography (TTE)

JK

NGS-JK-L33579, Transesophageal Echocardiography (TEE)

JK

NOVITAS-JL-L35434, Oximetry Services

JL

A57205, Billing and Coding: Oximetry Services

JL

A56809, Billing and Coding: Transesophageal Echocardiography (TEE)

A56580, Billing and Coding: Computerized Axial Tomography (CT), Thorax

A57326, Billing and Coding: Electrocardiograms

A57224, Billing and Coding: Respiratory Care

A57306, Billing and Coding: Transthoracic Echocardiography (TTE)

Related Codes

I26.94(20 policies)I26.99(20 policies)I26.02(20 policies)I26.09(20 policies)I26.93(20 policies)I26.92(20 policies)I26.01(20 policies)S26.01XA(20 policies)

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