E43 — Unspecified severe protein-calorie malnutrition
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
- All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
- The submitted medical record must support the selected ICD-10-CM code(s), and the submitted CPT/HCPCS code must accurately describe the service performed.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- For tests that currently lack specific CPT codes (functional intracellular analysis and total antioxidant function), bill using CPT 84999 and add a note identifying which test was performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
- Coverage and reasonable/necessary determinations for assays for vitamins and metabolic function are governed by LCD L34914 and claims must meet that LCD's requirements to be covered.
- Vitamin D assay testing billed to Medicare Part A or Part B MAC is covered when ordered by an authorized provider (physician or state-authorized non-physician) and the service is otherwise consistent with local coverage determination L33996.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition prompting the Vitamin D assay must be reported on the claim; for diagnostic tests, report the test result if known, otherwise report the presenting symptoms.
- When a referring/ordering provider is required, the referring/ordering provider name and NPI must be reported on the claim.
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
18 Active Policies
L37535 — Vitamin D Assay Testing
J06
A57736 — Billing and Coding: Vitamin D Assay Testing
J06
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A56416
Related Codes
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