A03.9 — Shigellosis, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
- An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
- The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
- The medical record must document relevant medical history and the results of pertinent tests or procedures.
Key Coverage Criteria
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
- A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
- Pharmacogenomics (PGx) testing is covered when it is reasonable and necessary per LCD L39063 and Medicare coverage rules for the beneficiary's clinical indication.
- CPT 81418 (PGx multi-gene panel) is covered when the test assays at least 6 genes, including CYP2C19 and CYP2D6 and CYP2D6 duplication/deletion analysis, and the panel is clinically indicated to guide drug therapy.
- A clinician-ordered single gene or allele test is considered covered when the billed component corresponds to the single gene/allele that was reasonable and necessary, even if the laboratory platform concurrently interrogated other genes operationally.
- Germline testing panels that include some previously tested genetic content may be covered if there is established clinical utility for the remaining non-duplicative genetic components of the panel.
13 Active Policies
A59914 — Billing and Coding: Pharmacogenomic Testing
J06
A58963 — Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)
J06
A59915 — Billing and Coding: Pharmacogenomic Testing
J06
L39995 — Pharmacogenomic Testing
J06
L39226
Related Codes
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