Does K92.81 require prior authorization?

No, K92.81 does not require prior authorization (high confidence). Code is covered without prior authorization.

`K92.81` — Gastrointestinal mucositis (ulcerative)

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
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.
EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy

J09

A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

J09

Ask Verity about documentation requirements, denial risks, or coverage in your state.