K22.5 — Diverticulum of esophagus, acquired
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.
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- Claims for swallowing studies should include documentation consistent with LCD L33449; this billing guideline is a complement to that LCD and providers should retain medical records supporting the medical necessity of the dysphagia evaluation.
Key Coverage Criteria
- Swallowing studies (videofluoroscopic or radiologic studies described by CPT 70370, 70371, or 74230) performed for evaluation or diagnosis of dysphagia are the intended covered service per this billing guideline and LCD L33449.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
- Instrumental assessment of swallowing (videofluoroscopic Modified Barium Swallow, MBS) is covered for patients with dysphagia who have documented pharyngeal dysfunction or are at risk for aspiration.
- Instrumental assessment is covered when a prior clinical (noninstrumental) swallowing examination identifies a problem that cannot be resolved without further instrumental assessment.
- Covered for patients with stroke or other central nervous system (CNS) disorders with associated speech and swallowing impairment.
13 Active Policies
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
Related Codes
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