Does Z80.0 require prior authorization?

No, Z80.0 does not require prior authorization (high confidence). Covered without prior authorization.

`Z80.0`, Family history of malignant neoplasm of digestive organs

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Select the CPT code that accurately describes the diagnostic/therapeutic procedure that was performed or attempted during the colonoscopy.
Append the -PT modifier to the selected CPT code to indicate a screening colonoscopy was converted to a diagnostic or therapeutic procedure.
Use an appropriate ICD-10 diagnosis code indicating the procedure was a screening (example: Z80.0) when submitting the claim for a converted screening colonoscopy.
Document clinical findings in the medical record that demonstrate the screening colonoscopy was converted to diagnostic/therapeutic (e.g., description of encountered pathology and performed intervention).

If a screening colonoscopy encounters pathology that necessitates intervention converting it to a diagnostic or therapeutic colonoscopy, bill using the appropriate diagnostic/therapeutic CPT code appended with the -PT modifier and an appropriate screening ICD-10 diagnosis.
When beneficiaries are at high risk for colorectal malignancy, an ICD-10 screening code such as Z80.0 (family history of malignant neoplasm of digestive organs) may be used to indicate the procedure was a screening converted to diagnostic/therapeutic.
A colonoscopy attempt that cannot be completed because of extenuating/unforeseen circumstances (e.g., inability to advance the colonoscope to the cecum or to a colon–small intestine anastomosis) is considered an incomplete/failed colonoscopy.
Policy applies to both screening and diagnostic colonoscopies.
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.

HUMANA-GENETIC-TESTING-FOR-HEREDITARY-COLORECTAL-AND-UTERINE-CANCER-MA, Genetic Testing for Hereditary Colorectal and Uterine Cancer

ANTHEM-CG-MED-70, Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CIGNA-A004, Preventive Care Services

AETNA-CPB-0352, Tumor Markers

AETNA-CPB-0535, Virtual Gastrointestinal Endoscopy

Ask Backwork about documentation requirements, denial risks, or coverage in your state.