Does M00.161 require prior authorization?

No, M00.161 does not require prior authorization (low confidence). No active coverage policies found for this code.

`M00.161` — Pneumococcal arthritis, right knee

ICD-10-CM

No Prior Auth Required

No active coverage policies found for this code (low confidence)

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim and the beneficiary medical record must support the use of the selected ICD-10-CM code(s).
If applicable, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the required claim fields: Part B (Loop 2400/SV101-7 or Item 19 paper), Part A (SV202-7 or UB04 Block 80); do not add extra characters when entering DEX Z-code on SV101-7.
Tests billed with CPT 87999 require submission of a Z-code and will undergo a MolDX Technical Assessment (TA).
Claims for expanded (>5 pathogen) RP/PNP/GI panels billed outside POS 19/21/22/23 must include documentation that the ordering provider meets specialist requirements or a geographic-access exception and must include an ICD-10 diagnosis code from Group 6 or 7 in addition to a sign or symptom code from Group 1 or 2 as applicable.

FDA-approved/cleared molecular infectious disease pathogen identification tests performed consistent with their intended use and billed with an appropriate accompanying ICD-10-CM diagnosis code are covered without a DEX Z-code.
Expanded (>5 pathogens) respiratory (RP), pneumonia (PNP), and gastrointestinal (GI) panels are covered when billed from Place of Service (POS) 19, 21, 22, or 23.
Expanded (>5 pathogens) RP/PNP panels for immune-competent beneficiaries are covered when ordered by an Infectious Disease specialist, or by a Pulmonologist (for RP/PNP) or Gastroenterologist (for GI) who is diagnosing and treating the beneficiary, with appropriate documentation and ICD-10 codes as required.
Expanded (>5 pathogens) RP/PNP/GI panels for immune-compromised beneficiaries are covered when ordered by a clinician specialist in Infectious Diseases, Oncology, Transplant, Pulmonology (RP/PNP), or Gastroenterology (GI) who is diagnosing and treating the beneficiary, with required documentation and ICD-10 codes.
Pre-transplant evaluation molecular panels for immune-compromised beneficiaries are covered regardless of symptoms when clear documentation of the pre-transplant evaluation accompanies the claim.
When a panel does not include an organism and separate testing for that organism is ordered and supported by medical record documentation, the separate test may be considered reasonable and necessary and covered.

A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J05

A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J05

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