N36.0 — Urethral fistula
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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 medical record must document the ordering provider's assessment related to the visit complaint, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that support medical necessity.
- Diagnostic test results should be reported on the claim if known; if results are not available, report the symptoms prompting the test.
- For services requiring a referring/ordering physician, the claim must include the referring/ordering physician's name and NPI; for Part A MAC claims using GA modifier, occurrence code 32 and the ABN date are required and ABN Form CMS-R-131 should be signed when applicable.
Key Coverage Criteria
- Cystometrogram (CPT 51725, 51726) is covered when performed to evaluate detrusor contractions, abnormalities of bladder compliance, measure post-void residual, determine bladder capacity, or detect detrusor sphincter dyssynergia (DSD).
- Uroflowmetry (CPT 51736, 51741) is covered when used to measure urine flow rate to evaluate suspected reduced detrusor function (eg, neurologic lesion), obstructive causes (eg, BPH, cystocele), or increased flow suggesting stress urinary incontinence (SUI) or intrinsic sphincter dysfunction (ISD).
- Urethral pressure profile studies (CPT 51727) are covered when other noninvasive tests are inconclusive and the study is needed to rule out severe urethral incompetence or for limited applications such as artificial urinary sphincter evaluation.
- Stimulus evoked response testing (CPT 51792) is covered when used to evaluate suspected cauda equina syndrome or other indications where this neurophysiologic test is clinically indicated.
- Voiding pressure studies (CPT 51728, 51729) are covered when the patient is able to void and the test is needed to measure detrusor contractility and detect outlet pressure obstruction.
- Intra-abdominal voiding pressure measurement (CPT 51797) is covered when used to account for intra-abdominal pressure components in the bladder pressure curve to better evaluate true detrusor function.
7 Active Policies
A57455 — Billing and Coding: Urodynamics
J06
L33576 — Urodynamics
J06
A56802 — Billing and Coding: Urodynamics
AETNA-CPB-0587 — Pancreas Kidney Transplantation
L34415 — CT of the Abdomen and Pelvis
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