Does 47535 require prior authorization?

No, 47535 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 47535?

Medicare facility rate: $169.34. Non-facility rate: $848.38. Work RVU: 3.85.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

3.85

Facility

$169.34

Non-Facility

$848.38

For decisions about preoperative biliary drainage: documentation of rationale for PBD if performed given evidence that routine PBD may increase infectious complications
Operative and peri-operative records documenting reconstruction technique (antecolic vs retrocolic), use of Braun anastomosis, omental/falciform wraps, stent placement, fibrin patch application, and rationale for such adjuncts (since evidence varies and practices may be individualized)
No explicit 'Documentation Requirements' section is provided in the text. (The policy repeatedly states that codes/procedures are 'covered if selection criteria are met' but does not list the selection criteria.)
Inferred documentation to support coverage (not explicitly listed in the CPB) should include: clinical diagnosis corresponding to a covered ICD-10 code (e.g., pathology or imaging confirming pancreatic adenocarcinoma, IPMN with high-grade dysplasia or invasive cancer, neuroendocrine tumor, chronic pancreatitis, duodenal neoplasm, ampullary carcinoma/adenoma, cholangiocarcinoma, combined pancreatic/duodenal injury)

Surgical resection of endocrine tumors (gastrinomas) including management of Zollinger-Ellison syndrome (ZES), with and without multiple endocrine neoplasia type 1 (MEN1)
Resection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas
C24.1 Malignant neoplasm of ampulla of Vater
D13.2 Benign neoplasm of duodenum
D13.5 Benign neoplasm of extrahepatic bile ducts
Pancreaticoduodenectomy (also known as Whipple resection) : CPT codes covered if selection criteria are met : 48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple- hyphen type procedure); with pancreatojejunostomy

AETNA-CPB-0365 — Pancreaticoduodenectomy (Whipple Resection)

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