K92.0 — Hematemesis
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.
- The patient's medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
Key Coverage Criteria
- Capsule endoscopy (CPT 91110, 91111 global) is payable under Medicare Part B when performed in office (POS 11), independent diagnostic testing facility (POS 49), or independent clinic (POS 49).
- Technical component codes 91110-TC and 91111-TC are payable under Part B in office (11), IDTF (49), independent clinic (49), federally qualified health center (50), and rural health clinic (72).
- Professional component codes 91110-26 and 91111-26 are payable under Part B in office (11), outpatient hospital (19 and 22), inpatient hospital (21), independent clinic (49), and public health clinic (71).
- When capsule endoscopy is normal but compelling symptoms persist, irritable bowel syndrome or abdominal pain diagnosis codes K58.0, K58.9, R10.11-R10.13, R10.2, R10.31-R10.33, or R10.84 are on the list of covered diagnoses and may be used.
- Report Patency Capsule Testing using CPT 91299 and enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or electronic equivalent); the ingestion of the capsule is part of the test.
- Telemetric gastrointestinal capsule imaging includes a technical component (capsule provision, hookup, downloading/processing) and a professional component (image review and interpretation with report); report the technical component's place of service as the location where the image download to the computer is performed.
18 Active Policies
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
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