Does N04.9 require prior authorization?

No, N04.9 does not require prior authorization (high confidence). Code is covered without prior authorization.

`N04.9` — Nephrotic syndrome with unspecified morphologic changes

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
Medical records must document that applicable LCD coverage criteria are met and that the test is expected to influence treatment; include relevant history, exam findings, problems/diagnoses, and data (labs, imaging) that support the ordering decision.

Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
MS testing is covered when performed in accordance with the applicable Local Coverage Determination (LCD) coverage guidelines for monoclonal gammopathy.
Mass spectrometry (MS) testing is covered when the medical record documents that the testing is expected to influence the treatment or management of the condition for which the test is ordered.
Retroperitoneal ultrasound is indicated for evaluation of the pancreas for diagnosis and management of retroperitoneal abnormalities.
Retroperitoneal ultrasound is indicated to measure and follow the abdominal aorta, including monitoring patients with aortic aneurysms.

A58921 — Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

J06

L39189 — Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

J06

A55336 — Billing and Coding: Retroperitoneal Ultrasound

L34577 — Retroperitoneal Ultrasound

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