N41.3 — Prostatocystitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
- Documentation supporting the service must be available to Medicare upon request.
- When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI.
Key Coverage Criteria
- Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
- Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
- FDA-approved or cleared molecular infectious disease tests performed consistent with their intended use labeling are covered without a DEX Z-Code and Technical Assessment when billed with appropriate ICD-10-CM diagnosis codes and supporting documentation.
- Expanded (>5 pathogens) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered if billed from place of service (POS) 19, 21, 22, or 23, or if ordered by an appropriate specialist depending on beneficiary immune status and the specialist is diagnosing/treating the beneficiary.
- For immune-compromised beneficiaries, expanded panels (RP/PNP/GI/other panels) are covered when ordered by a specialist in Infectious Diseases, Oncology, Transplant, Pulmonology (for RP/PNP), or Gastroenterology (for GI) who is diagnosing and treating the beneficiary.
- Pre-transplant evaluation testing for an immune-compromised beneficiary is covered regardless of symptoms when clear documentation of the pre-transplant evaluation accompanies the claim.
12 Active Policies
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
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
Related Codes
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