D78.11 — Accidental puncture and laceration of the spleen during a procedure on the spleen
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- The ordering/referring practitioner's assessment related to the patient's complaint and the specific reason for the test must be documented in the medical record.
- The medical record must contain a referral/order on file for each non‑invasive vascular study performed.
- Results of pertinent tests and procedures performed that relate to the indication must be included in the medical record and reported on the claim if known; otherwise report the symptoms that prompted the test.
Key Coverage Criteria
- Non-invasive vascular diagnostic tests are covered when ordered by the treating practitioner or a consulting physician who will use the results to manage the beneficiary's specific medical problem.
- A documented referral/order must be on record for each individual non-invasive vascular study performed for coverage to apply.
- Cerebrovascular arterial duplex follow-up is covered annually for stenosis 20–49% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 50–79% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 80–99% if surgical correction has not been performed.
- After carotid endarterectomy, repeat ipsilateral (unilateral) duplex examinations are allowable at approximately six weeks, six months, and one year post‑procedure during the first year.
5 Active Policies
A59920 — Billing and Coding: Non-Invasive Vascular Studies
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
A56697 — Billing and Coding: Non-Invasive Vascular Studies
L34415 — CT of the Abdomen and Pelvis
L34045 — Non-Invasive Vascular Studies
Related Codes
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