K61.4 — Intrasphincteric abscess
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
- Documentation supporting the service must be available to Medicare upon request.
Key Coverage Criteria
- Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
- TRUS is covered for evaluation of suspected prostatitis or suspected prostatic abscess.
- TRUS is covered to evaluate congenital or acquired cystic conditions of the prostate, seminal vesicles, and related tissues.
- Transrectal ultrasound (TRUS) is covered for clinical staging of proven prostate cancer when radical prostatectomy or radiation therapy is being considered.
- TRUS is covered for evaluation of a patient after radical prostatectomy or radiation therapy for prostate cancer who has rising prostate specific antigen (PSA) levels.
- TRUS is covered when there is a documented suspicion of prostatic disease based on patient history, abnormal digital rectal examination, or a clinically significant PSA increase.
5 Active Policies
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
ANTHEM-CG-RAD-28 — CG-RAD-28 Transrectal Ultrasonography
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
Related Codes
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