D16.5 — Benign neoplasm of lower jaw bone
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.
- Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.
- Submitted medical record must support the use of the selected diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, ongoing documentation of any changes in course of treatment, and DHV as noted in the covered indications section.
Key Coverage Criteria
- Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy.
- CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
- CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.
- Flow cytometry interpretation is reported using CPT codes 88187–88189 (one interpretation code per specimen).
- Quantitative cell counts by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361, and 86367.
- Flow cytometry services are payable under Medicare Part B at specified places of service according to CPT: groups of CPTs have defined allowable POS (see mapping in policy).
19 Active Policies
L36850 — Peripheral Nerve Blocks
J06
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
A55315 — Billing and Coding: Proton Beam Therapy
A56464 — Billing and Coding: Flow Cytometry
A56580 — Billing and Coding: Computerized Axial Tomography (CT), Thorax
Related Codes
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