K91.858 — Other complications of intestinal pouch
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The submitted CPT/HCPCS code must accurately describe the service performed.
- All documentation must be maintained in the patient medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., 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.
Key Coverage Criteria
- Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
- A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Diagnostic colonoscopy is covered when determined to be reasonable and necessary in accordance with Local Coverage Determination L38812.
- EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
12 Active Policies
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33671 — Diagnostic Colonoscopy
J09
A55937 — Billing and Coding: Diagnostic Colonoscopy
J09
L38812
Related Codes
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