J36, Peritonsillar abscess
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
- Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.
Key Coverage Criteria
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- Coblation of soft tissue stenosis of the external auditory canal (EAC) (case series in children with congenital/acquired EAC occlusion showing patency and symptom resolution).
- Cordotomy by Coblation (Coblator cordotomy) for treatment of bilateral vocal fold immobility (BVFI) to improve airway (multiple series including larger retrospective series reporting de-cannulation and improved Dyspnea Index/VHI outcomes).
- Coblation (RF cold ablation) for recurrent laryngotracheal respiratory papillomatosis (small series reporting longer intervals between interventions vs CO2 laser).
- Low-temperature RF Coblation for select early-stage glottic cancer (small series reporting feasibility, voice preservation, and no major complications in short follow-up).
2 Active Policies
AETNA-CPB-0475, Coblation
A57204, Billing and Coding: MRI and CT Scans of the Head and Neck
Related Codes
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