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ICD-10-CM S36.428A, Contusion of other part of small intestine, initial encounter | No Prior Auth

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`S36.428A`, Contusion of other part of small intestine, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high 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.
Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
Report overnight oximetry using CPT code 94762 on claims.

Medical records must document the signs, symptoms, diagnosis, or clinical rationale that meet one of the covered indications (e.g., acute respiratory symptoms, chronic respiratory/cardiopulmonary/neuromuscular disease and the specific reason for oximetry).

Providers should retain records and be prepared for post-payment data analysis and subsequent medical review audits related to oximetry services.

Services performed in an Independent Diagnostic Testing Facility (IDTF) must follow related LCD L35448 and Local Coverage Article A53252 billing and coding requirements (refer to those documents for IDTF-specific documentation and billing requirements).

Key Coverage Criteria

Oximetry is medically necessary for patients exhibiting acute respiratory dysfunction signs or symptoms (tachypnea, dyspnea, cyanosis, respiratory distress, confusion, or hypoxia).
Oximetry is medically necessary for patients with chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease affecting respiratory muscles when used for initial evaluation to determine the severity of respiratory impairment.
Oximetry is medically necessary for patients with chronic lung disease, severe cardiopulmonary disease, or neuromuscular respiratory muscle disease to evaluate an acute change in condition.
Oximetry is medically necessary to evaluate exercise tolerance in a patient with respiratory disease.
Oximetry is medically necessary to establish the medical necessity of an oxygen therapeutic regimen in patients with chronic respiratory, cardiopulmonary, or neuromuscular disease affecting respiration.
Oximetry is medically necessary for patients with sustained severe multiple trauma or who present with acute severe chest pain.

4 Active Policies

NOVITAS-JH-L35434, Oximetry Services

JH

NOVITAS-JL-L35434, Oximetry Services

JL

A57205, Billing and Coding: Oximetry Services

JL

A56421, Billing and Coding: CT of the Abdomen and Pelvis

Related Codes

C34.02(4 policies)C34.2(4 policies)C34.00(4 policies)C34.01(4 policies)C34.11(4 policies)C34.12(4 policies)C33(4 policies)C34.31(4 policies)

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