N43.0 — Encysted hydrocele
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The ordering/referring practitioner's assessment related to the patient's complaint and the specific reason for the test must be documented in the medical record.
- The medical record must contain a referral/order on file for each non‑invasive vascular study performed.
- Results of pertinent tests and procedures performed that relate to the indication must be included in the medical record and reported on the claim if known; otherwise report the symptoms that prompted the test.
- Signed and dated office visit notes and operative reports must be present in the record for the services ordered or rendered to Medicare beneficiaries.
Key Coverage Criteria
- Non-invasive vascular diagnostic tests are covered when ordered by the treating practitioner or a consulting physician who will use the results to manage the beneficiary's specific medical problem.
- A documented referral/order must be on record for each individual non-invasive vascular study performed for coverage to apply.
- Cerebrovascular arterial duplex follow-up is covered annually for stenosis 20–49% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 50–79% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 80–99% if surgical correction has not been performed.
- After carotid endarterectomy, repeat ipsilateral (unilateral) duplex examinations are allowable at approximately six weeks, six months, and one year post‑procedure during the first year.
9 Active Policies
L35755 — Non-Invasive Abdominal / Visceral Vascular Studies
J05
A57591 — Billing and Coding: Non-Invasive Abdominal / Visceral Vascular Studies
J05
AETNA-CPB-0327 — Infertility
AETNA-CPB-0532 — Scrotal Ultrasonography
ANTHEM-CG-RAD-27 — CG-RAD-27 Scrotal Ultrasound
Related Codes
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