Does A04.3 require prior authorization?

No, A04.3 does not require prior authorization (high confidence). Code is covered without prior authorization.

`A04.3` — Enterohemorrhagic Escherichia coli infection

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
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.
A colonoscopy may be billed when a sigmoidoscope is used only if the bowel is sufficiently short that the entire colon can be examined and this fact is clearly documented in the clinical record.

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

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