Does T79.A12A require prior authorization?

No, T79.A12A does not require prior authorization (high confidence). Covered without prior authorization.

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`T79.A12A`, Traumatic compartment syndrome of left upper extremity, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The referring physician/nonphysician practitioner must state the clinical indication/medical necessity in the order for the test and provide the order to the performing provider.
The medical record must include a permanent report describing studies performed, any contrast or radiopharmaceuticals used, known significant reactions/complications, and comparisons with prior relevant studies.
Reports must document both normal and abnormal findings, measurements for variations from normal, and explicitly address the clinical question or explain why it cannot be answered.

Retention of ultrasound images must meet clinical need and applicable legal and facility requirements, and test results must be shared with the referring physician.

If the performing provider is different from the ordering provider, the performing provider must maintain a copy of test results, interpretation, and the ordering provider's order; medical records must be available to Medicare upon request.

Documentation must support the medical necessity for each study reported, the number of services billed, and any concurrent imaging studies (e.g., Doppler/vessel mapping with arteriogram) to justify performance and reimbursement.

Key Coverage Criteria

Non-invasive peripheral venous and hemodialysis access studies are covered when the results will be used to guide the clinical management of the patient.
Duplex scanning and physiologic studies may be performed and reimbursed during the same encounter when physiologic studies are abnormal or when evaluating vascular trauma, thromboembolic events, or aneurysmal disease.
One preoperative scan for hemodialysis access site surgery is covered to plan access creation.
Pre-surgical radial artery conduit mapping may be accompanied by vein mapping only when arterial studies show an unacceptable conduit or insufficient arterial conduit is available for multiple bypass procedures.
Non-invasive peripheral venous vascular studies are medically necessary when all three conditions are met: signs or symptoms of ischemia or altered blood flow are present; the information is necessary for appropriate medical or surgical management; and the test is not redundant of other diagnostic procedures.
Objective testing for deep vein thrombosis (DVT) is allowed in patients who are candidates for anticoagulation or invasive therapies and who have clinical signs or symptoms of DVT, including edema, tenderness, inflammation, or erythema.

3 Active Policies

WPS-J5-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

A57594, Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

WPS-J8-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

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T79.A12A, Traumatic compartment syndrome of left upper extremity, initial encounter