K86.1 — Other chronic pancreatitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient medical record and made available to the contractor upon request, with every page legible and including patient identification (complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Results of the vitamin D testing and the resulting treatment regimen must be documented in the patient's medical record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures (e.g., progress notes and written laboratory reports).
Key Coverage Criteria
- 25-hydroxy vitamin D testing (including fractions, if performed) is covered when deemed reasonable and necessary per Local Coverage Determination L33771.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
20 Active Policies
L37535 — Vitamin D Assay Testing
J06
A57736 — Billing and Coding: Vitamin D Assay Testing
J06
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33771 — Vitamin D; 25 hydroxy, includes fraction(s), if performed
J09
A56841 — Billing and Coding: Vitamin D; 25 hydroxy, includes fraction(s), if performed
Related Codes
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