Does Z98.61 require prior authorization?

No, Z98.61 does not require prior authorization (high confidence). Covered without prior authorization.

`Z98.61`, Coronary angioplasty status

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.

Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
Cardiovascular nuclear medicine testing is reimbursable for risk assessment or re-evaluation in asymptomatic patients or patients with stable symptoms who have known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, provided the patient has not undergone a revascularization procedure within the prior 2 years.
Blood pool scan to assess left ventricular ejection fraction prior to implantation of an implantable cardioverter-defibrillator (ICD) or biventricular pacemaker is covered when the medical record documents the intended plan for device insertion and the test result.

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J15-L33960, Cardiovascular Nuclear Medicine

J15

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

CGS-J18-L33960, Cardiovascular Nuclear Medicine

J18

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