E16.1 — Other hypoglycemia
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.
- This article provides billing, coding and guideline information that complements Local Coverage Determination (LCD) L33431 for HbA1c; refer to LCD L33431 for clinical coverage criteria and specific documentation requirements.
- All documentation supporting MAC must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
- Perform HbA1c testing at least twice per year in patients who are meeting individualized treatment goals and have stable glycemic control, defined as two consecutive HbA1c results meeting treatment goals.
- Perform HbA1c testing for beneficiaries with unstable or uncontrolled glycemia at intervals up to once every 3 months as allowed by the Lab NCD 190.21.
7 Active Policies
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
A56686 — Billing and Coding: HbA1c
AMBETTER-CG-Metab-Endo-Mito-DO-2025.1 — Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders
L34415 — CT of the Abdomen and Pelvis
Related Codes
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