G90.519 — Complex regional pain syndrome I of unspecified upper limb
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims and documentation requirements for CPNB are governed by and must follow the Local Coverage Determination L37641 referenced by this guideline.
- Maintain complete, legible medical records for every page with patient identifiers and dates of service; records must be available to the contractor upon request.
- Include the legible signature of the physician or non-physician practitioner responsible for the care and ensure the submitted record supports the selected ICD-10-CM and CPT/HCPCS codes.
- Retain and provide information about the equipment used for ANS studies when requested to demonstrate compliance with equipment and procedural requirements.
Key Coverage Criteria
- No specific coverage indications are stated in this billing/coding guideline; refer to Local Coverage Determination L37641 for covered indications for continuous peripheral nerve blocks (CPNB).
- Report CPT 95921 when at least two parasympathetic cardiovagal tests are performed (heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio).
- Report CPT 95922 when both vasomotor adrenergic components are performed: Valsalva maneuver with beat-to-beat blood pressure and R-R interval changes AND at least five minutes of passive tilt testing.
- Report CPT 95924 only when both parasympathetic (cardiovagal) and vasomotor adrenergic functions are tested together and passive tilt of at least five minutes is included.
- Perform QSART to evaluate integrity of distal postganglionic sympathetic sudomotor fibers in diabetic and other autonomic neuropathies or progressive autonomic disorders to determine severity and distribution of sympathetic deficit.
- NC-stat testing (CPT 95905) is allowed when the beneficiary has a high pre-test or prior probability of Carpal Tunnel Syndrome (CTS), limited to one service per arm.
12 Active Policies
L35098 — Nerve Conduction Studies and Electromyography
J06
A57668 — Billing and Coding: Nerve Conduction Studies and Electromyography
J06
A57651 — Billing and Coding: Autonomic Function Tests
J09
L33609 — Autonomic Function Tests
J09
L33933
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