Does Z13.810 require prior authorization?

No, Z13.810 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z13.810`, Encounter for screening for upper gastrointestinal disorder

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

For MBSS: documentation that MBSS is being performed by both a speech-language pathologist and a radiologist when dysphagia has been diagnosed and when one or more indications are present (clinical swallow evaluation identifies aspiration risk; follow-up of known swallowing disorder; need to determine diet/liquid consistency; need to determine effectiveness of maneuvers).
Clinical swallow evaluation results must be documented when used to justify MBSS or FEES (e.g., documentation that clinical exam identifies risk of aspiration or persistent dysphagia).

For FEES/FEESST: documentation of the specific clinical rationale meeting any of the listed reasons that make FEES preferred (e.g., aspiration-of-barium concerns, need to assess fatigue during a meal, repeat exam to assess change, severe dysphagia with poor swallow reflex, therapeutic exam requiring multiple maneuvers/real foods, need to visualize larynx post-intubation/surgery, problematic positioning/transportation for fluoroscopy, suspicion of compromised laryngeal competence with tracheostomy, transportation barriers).

Documentation of contraindications/ability to undergo MBSS as applicable (ability to swallow and be positioned, absence of need for frequent suctioning, absence of tachypnea, absence of barium allergy) when MBSS is selected.

Key Coverage Criteria

Modified barium swallow study (MBSS) to evaluate function of the swallowing mechanism when performed by a speech-language pathologist and radiologist when dysphagia has been diagnosed, and there is a need for further follow-up, as indicated by one or more of the following: Need to determine effectiveness of swallowing postures, maneuvers, or strategies to reduce risk of aspiration.
Both fiberoptic endoscopy and videofluoroscopy for evaluation of swallowing function.
FEES is the preferred test over videofluoroscopy in the evaluation of a swallowing disorder in any of the following conditions: A more conservative examination than videofluoroscopy is required because of concerns about aspiration of barium, food, and/or liquid.
FEES is preferred when there is a need to assess fatigue or swallowing status over a meal.
FEES is preferred for repeat examination to assess change; to assess effectiveness or need for maneuvers.
FEES is preferred for severe dysphagia with very weak or possibly absent swallow reflex and/or very limited ability to tolerate any aspiration (e.g., brainstem stroke, member tube-fed for prolonged period, very poor pulmonary status, or poor immunologic status).

4 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0248, Fiberoptic Endoscopic Evaluation of Swallowing (FEES)/Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) and Laryngopharyngeal Endoscopic Esthesiometer (LPEER)

AETNA-CPB-0608, Salivary Tests

AETNA-CPB-0738, Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy

`Z13.810`, Encounter for screening for upper gastrointestinal disorder

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

Z13.810, Encounter for screening for upper gastrointestinal disorder

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

`Z13.810`, Encounter for screening for upper gastrointestinal disorder