K31.6 — Fistula of stomach and duodenum
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 and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Key Coverage Criteria
- 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.
- EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
- EGD is covered for upper abdominal distress accompanied by a short history of concerning signs or symptoms such as weight loss, anorexia, vomiting, or NSAID/other gastric irritant intake.
- EGD is covered for patients older than 40 years who have a significant history of heartburn that recurs after a course of symptomatic therapy.
- EGD is covered for patients with dysphagia or odynophagia.
8 Active Policies
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — 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
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.