K80.41 — Calculus of bile duct with cholecystitis, unspecified, with obstruction
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.
- Vitamin D assay testing is payable under Medicare Part B when performed in an office (POS 11), independent clinic (POS 49), Federally Qualified Health Center (POS 50), or independent laboratory (POS 81).
- Non-physician practitioners (e.g., nurse practitioners, clinical nurse specialists, physician assistants) may certify, order, and establish the plan of care for Vitamin D assay testing as authorized by State law (outpatient settings other than CORFs).
- 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.
11 Active Policies
A57484 — Billing and Coding: Vitamin D Assay Testing
J05
L34658 — Vitamin D Assay Testing
J05
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57414
Related Codes
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