K94.13 — Enterostomy malfunction
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes per Final Rule 1713 and the LCD-related Standard Documentation Requirements Article (A55426); claims missing these will be denied.
- For quantities of supplies that exceed the usual maximum amount, the medical record must explain the need for the increased amount and be available upon request.
- Initial justification for medical need must be established at the time the ostomy item is first ordered; once initial need is established, ongoing need is assumed and no further documentation is required as long as the beneficiary continues to meet the Prosthetic Devices benefit.
- Claims for tape and adhesive (A4450, A4452, A5120) must include an AU modifier or another appropriate modifier indicating alternate coverage; absence of such modifier will cause rejection for missing information.
Key Coverage Criteria
- Ostomy supplies are covered under the Prosthetic Device benefit for beneficiaries with a permanent impairment requiring an ostomy; permanence means a condition of long and indefinite duration as documented by the treating practitioner.
- Ostomy supplies are covered for use on beneficiaries with a surgically created opening (stoma) to divert urine or fecal contents, including colostomy, ileostomy, and urinary ostomy.
- 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.
13 Active Policies
A55937 — Billing and Coding: Diagnostic Colonoscopy
J09
L33671 — Diagnostic Colonoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A58428
Related Codes
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