H90.A31 — Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must contain documentation that fully supports the medical necessity of the services provided.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- Diagnosis code(s) reported on the claim must best describe the patient's condition for which the service was performed; missing or invalid codes will result in claim return.
- Because CPT does not define a re-evaluation code for speech-language pathology, use the evaluation CPT code to report re-evaluations and document minutes the same as for initial evaluations.
Key Coverage Criteria
- Speech-language pathology services are covered for diagnosis and treatment of speech and language disorders that result in communication disabilities.
- Speech-language pathology services are covered for diagnosis and treatment of swallowing disorders (dysphagia).
- Services are covered when provided by a qualified speech-language pathologist who holds a Certificate of Clinical Competence (CCC-SLP) or is in the clinical fellowship year (CFY) accumulating supervised experience required for certification.
- Services are covered when they are a specific and effective treatment under accepted standards of medical practice for the patient's condition.
- Services are covered when the level of complexity or the patient's condition requires that the services can be safely and effectively performed only by or under the supervision of a qualified therapist (skilled care required).
- Rehabilitative therapy is covered when the patient has potential to improve or is improving, maximum improvement has not been attained, and anticipated improvement is attainable in a reasonable and generally predictable period.
20 Active Policies
L33580 — Speech-Language Pathology
J06
A52866 — Billing and Coding: Speech-Language Pathology
J06
A57434 — Billing and Coding: Vestibular and Audiologic Function Studies
J12
L34975 — Neurophysiology Evoked Potentials (NEPs)
J12
L35007 — Vestibular and Audiologic Function Studies
Related Codes
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