76872
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.65
Facility
$3.45
Non-Facility
$3.45
Documentation Required
- Medical record documentation must show the diagnosis of Grade II or III hemorrhoids and that the patient failed prior rubber band ligation or conservative measures (behavior modification, high-fiber diet, topical hydrocortisone cream/suppositories).
- Claims for the procedure must be submitted using CPT code 46948 on the claim form.
- The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
Key Coverage Criteria
- Doppler-guided hemorrhoid artery ligation, with or without retroanal repair, is a covered service.
- Coverage is limited to patients with Grade II hemorrhoids.
- Coverage is limited to patients with Grade III hemorrhoids.
- Hemorrhoid artery ligation is covered only after failure of rubber band ligation or failure of conservative treatment (behavior modification, high-fiber diet, and topical hydrocortisone cream or suppositories).
- Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
14 Active Policies
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
L33693 — Peripheral Venous Ultrasound
J09
L35451 — Peripheral Venous Ultrasound
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
Related Codes
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