K80.36 — Calculus of bile duct with acute and chronic cholangitis without obstruction
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.
- All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
- An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
- The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
Key Coverage Criteria
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
- Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.
- Colonoscopy is covered for investigation of a positive fecal occult blood test.
- Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.
- Surveillance colonoscopy is covered for patients with a history of colorectal cancer or adenomatous polyps being followed for neoplasia surveillance.
7 Active Policies
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A57802 — Billing and Coding: Hepatic (Liver) Function Panel
L34005 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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