I85.11 — Secondary esophageal varices with bleeding
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
- All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
- For CID codes (T38.895*/T43.215*/T43.225*/T50.995*), the medical record must document the specific chemotherapy agent(s) causing the diarrhea and prior antidiarrheal treatments that have been ineffective.
- For VIPoma diagnosis codes (C25.4, C26.0, D13.7, D13.91, D13.99), the medical record must document that the patient’s diagnosis is VIPoma.
Key Coverage Criteria
- Octreotide is covered for chemotherapy-induced diarrhea (CID) when claim includes ICD-10-CM codes T38.895A/T38.895D/T38.895S, T43.215A/T43.215D/T43.215S, T43.225A/T43.225D/T43.225S, or T50.995A/T50.995D/T50.995S and the medical record documents the chemotherapy agent(s) causing the CID and prior antidiarrheal treatments that became ineffective.
- Octreotide is covered for treatment of VIPoma when claim includes ICD-10-CM codes C25.4, C26.0, D13.7, D13.91, or D13.99 and the medical record documents that the patient’s diagnosis is VIPoma.
- Octreotide may be considered when ICD-10-CM code R79.89 is submitted if the medical record documents abnormal clinical or laboratory findings that led to suspicion of VIPoma.
- Octreotide may be considered when ICD-10-CM code R94.7 is submitted if the medical record documents an abnormal octreotide scan that led to suspicion of VIPoma.
- Wireless capsule endoscopy of the small bowel (including esophagus through ileum) is billed with CPT 91110 when clinically indicated.
- Wireless capsule endoscopy limited to the esophagus is billed with CPT 91111 when clinically indicated.
19 Active Policies
A56704 — Billing and Coding: Wireless Capsule Endoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33674 — Duplex Scanning
J09
L33774 — Wireless Capsule Endoscopy
J09
A57636 — Billing and Coding: Duplex Scanning
Related Codes
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