0526T — Insj/rplcmt iims eltrd only
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Providers must comply with any additional documentation, prior authorization, or provider-qualification requirements specified in the referenced LCDs and Billing and Coding Articles.
Key Coverage Criteria
- Billing and coding for Category III codes is allowed only when the service meets the coverage indications, limitations, and medical necessity criteria described in LCD L35490 and the performing physician (MD/DO) meets all criteria in that LCD and this Billing and Coding Article.
- CPT 0446T, 0447T, and 0448T (creation/removal/replacement of implantable interstitial glucose sensor) are billed and covered only per LCD L38686 and Billing and Coding Article A58213 when all criteria in that LCD/article are met.
- CPT 0421T and HCPCS C2596 (transurethral waterjet ablation of the prostate and associated probe) are billed and covered only per LCD L38682 and Billing and Coding Article A58209 when all criteria in that LCD/article are met.
- Electrocardiographic (EKG/ECG) monitoring (Holter or real-time) billing and coverage follow LCD L34636 and Billing and Coding Article A57476 and are allowed when those LCD/article criteria are met.
- CCTA is indicated to determine the patency of coronary artery bypass grafts (CABG).
- CCTA is indicated as an alternative to invasive coronary angiography or stress testing for patients with anginal symptoms suggestive of coronary artery disease.
8 Active Policies
A56902 — Billing and Coding: Category III Codes
J05
L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J05
L38682 — Transurethral Waterjet Ablation of the Prostate
J05
L38837 — Colon Capsule Endoscopy (CCE)
J05
L38839
Related Codes
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