D13.99 — Benign neoplasm of ill-defined sites within the digestive system
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For CID codes (T38.895*/T43.215*/T43.225*/T50.995*), the medical record must document the specific chemotherapy agent(s) causing the diarrhea and prior antidiarrheal treatments that have been ineffective.
- For VIPoma diagnosis codes (C25.4, C26.0, D13.7, D13.91, D13.99), the medical record must document that the patient’s diagnosis is VIPoma.
- When code R79.89 is used, the medical record must document the abnormal clinical or laboratory findings that prompted suspicion of VIPoma.
- When code R94.7 is used, the medical record must document an abnormal octreotide scan that prompted suspicion of VIPoma.
Key Coverage Criteria
- Octreotide is covered for chemotherapy-induced diarrhea (CID) when claim includes ICD-10-CM codes T38.895A/T38.895D/T38.895S, T43.215A/T43.215D/T43.215S, T43.225A/T43.225D/T43.225S, or T50.995A/T50.995D/T50.995S and the medical record documents the chemotherapy agent(s) causing the CID and prior antidiarrheal treatments that became ineffective.
- Octreotide is covered for treatment of VIPoma when claim includes ICD-10-CM codes C25.4, C26.0, D13.7, D13.91, or D13.99 and the medical record documents that the patient’s diagnosis is VIPoma.
- Octreotide may be considered when ICD-10-CM code R79.89 is submitted if the medical record documents abnormal clinical or laboratory findings that led to suspicion of VIPoma.
- Octreotide may be considered when ICD-10-CM code R94.7 is submitted if the medical record documents an abnormal octreotide scan that led to suspicion of VIPoma.
- Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
- True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
13 Active Policies
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L36850 — Peripheral Nerve Blocks
J06
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
ANTHEM-CG-LAB-11
Related Codes
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