N42.30 — Unspecified dysplasia of prostate
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.
- Flow cytometry is covered for examination of body fluids (including peripheral blood and cerebrospinal fluid), bone marrow, and lymphoreticular tissues (lymph nodes, tonsil, spleen).
- Peripheral blood and fine needle aspirate specimens are acceptable for flow cytometry to avoid more invasive diagnostic procedures.
- Coverage decisions are governed by the associated Local Coverage Determination LCD L34215 and its specific coverage criteria.
- TRUS is covered for evaluation of suspected prostatitis or suspected prostatic abscess.
- TRUS is covered to evaluate congenital or acquired cystic conditions of the prostate, seminal vesicles, and related tissues.
8 Active Policies
L33578 — Transrectal Ultrasound
J06
A57427 — Billing and Coding: Transrectal Ultrasound
J06
AETNA-CPB-0698 — Prostate Biopsy
ANTHEM-CG-LAB-28 — CG-LAB-28 Prostate Specific Antigen Testing
A57690 — Billing and Coding: Lab: Flow Cytometry
Related Codes
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