Does G04.81 require prior authorization?

No, G04.81 does not require prior authorization (high confidence). Code is covered without prior authorization.

`G04.81` — Other encephalitis and encephalomyelitis

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.
Documentation should include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures supporting the need for visual fields testing.
The diagnosis code(s) reported on the claim must best describe the patient's condition for which the visual fields testing was performed.
Refer to NCCI and OPPS requirements prior to billing Medicare to ensure coding compliance and to determine any bundling or packaging edits.

Ambulatory continuous EEG is covered only if a prior routine “resting” EEG was performed before the ambulatory EEG.
Routine EEGs covered under this policy are those described by CPT codes 95812, 95813, 95816, 95819, or 95822.
A routine EEG is defined as a recording of less than a 24-hour continuous duration.
Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.

A57554 — Billing and Coding: Immune Globulins

J05

L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

L34771 — Immune Globulins

J05

A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

Ask Verity about documentation requirements, denial risks, or coverage in your state.