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ICD-10-CM T85.631A, Leakage of intraperitoneal dialysis catheter, initial encounter | No Prior Auth

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`T85.631A`, Leakage of intraperitoneal dialysis catheter, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.

The medical record must document relevant medical history and the results of pertinent tests or procedures.

For diagnostic tests, report the test result if known; if the result is not known at time of billing, report the symptoms that prompted the performance of the test.

A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.

Key Coverage Criteria

Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
Evaluation of an anorectal adenomatous polyp is covered (adenomatous polyps only).
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.

4 Active Policies

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J18

A56456, Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

A57206, Billing and Coding: Lumbar MRI

Related Codes

C78.5(4 policies)C7A.022(4 policies)C77.2(4 policies)C78.4(4 policies)C7A.020(4 policies)C7A.021(4 policies)C21.1(4 policies)C7A.023(4 policies)

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