Does 91113 require prior authorization?

No, 91113 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 91113?

Medicare facility rate: $29.80. Non-facility rate: $29.80. Work RVU: 2.35.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.35

Facility

$29.80

Non-Facility

$29.80

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
The submitted medical record must support the selected ICD-10-CM code(s) and, for diagnostic tests, report the test result if known; otherwise report the symptoms prompting the test.
For services requiring a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
The submitted CPT/HCPCS code must accurately describe the service performed and may be subject to NCCI or OPPS packaging edits; verify NCCI/OPPS before billing.

Colon capsule endoscopy (CCE) may be billed when an instrument (optical) colonoscopy was attempted but was incomplete, documented by ICD-10-CM code Z53.8.
CCE may be billed when optical colonoscopy is contraindicated as determined by a board-certified or board-eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training, documented by ICD-10-CM code Z53.09.
All uses of CCE must meet the reasonable and necessary requirements of Local Coverage Determination L38571.
Colon capsule endoscopy (CCE) is indicated when instrument colonoscopy has been attempted and was incomplete (use ICD-10-CM code Z53.8).
CCE is indicated when optical (instrument) colonoscopy is contraindicated as determined by evaluation by a board certified/board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training (use ICD-10-CM code Z53.09).
Coverage for CCE is contingent on meeting the reasonable and necessary requirements specified in Local Coverage Determination L38805.

A58471 — Billing and Coding: Colon Capsule Endoscopy (CCE)

J05

L35490 — Category III Codes

J05

L38837 — Colon Capsule Endoscopy (CCE)

J05

A58294 — Billing and Coding: Colon Capsule Endoscopy (CCE)

J06

L38571 — Colon Capsule Endoscopy (CCE)

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