H65.04 — Acute serous otitis media, recurrent, right ear
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
- All documentation must be maintained in the patient's medical record, be legible, include appropriate patient identification (e.g., full name) and dates of service, and be made available to the contractor upon request.
Key Coverage Criteria
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
- CPT codes 92553, 92557, and 92568 are allowable when the beneficiary has current long-term use of ototoxic antibiotics.
- The professional component (PC) of CPT codes 92537, 92538, 92541, 92542, 92544, 92545, 92546, 92587, 92588, 92651, 92652, and 92653 may be reported when the PC is performed in inpatient, outpatient, rehabilitation facilities, nursing facilities (when Part A benefits are exhausted), hearing and speech centers, independent clinics, or independent diagnostic testing facilities (IDTF).
6 Active Policies
A57473 — Billing and Coding: Allergy Testing
J05
L36402 — Allergy Testing
J05
A57434 — Billing and Coding: Vestibular and Audiologic Function Studies
J12
L35007 — Vestibular and Audiologic Function Studies
J12
A57181 — Billing and Coding: Allergy Testing
Related Codes
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