Does I31.31 require prior authorization?

Yes, I31.31 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

`I31.31` — Malignant pericardial effusion in diseases classified elsewhere

ICD-10-CM

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.

Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
Cardiac CT (CCT) or Coronary CT Angiography (CCTA) is covered when the patient's medical record documents medical necessity consistent with the indications and limitations set forth in the attached Local Coverage Determination (LCD).
Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.

A57552 — Billing and Coding: Coronary Computed Tomography Angiography (CCTA)

J05

L39913 — Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)

J05

L35121 — Coronary Computed Tomography Angiography (CCTA)

J05

L35490 — Category III Codes

J05

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