N43.3 — Hydrocele, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The ordering physician/nonphysician practitioner must state the clinical indication and medical necessity for the study in the order.
- The performing provider must maintain a permanent record of the performed study and interpretation, and must retain a copy of the ordering provider’s order and the test results.
- The report must describe the studies performed, note any contrast media or radiopharmaceuticals used, record any significant patient reactions or complications, and compare with prior relevant imaging.
- Variations from normal size must be documented with measurements and the report should address specific clinical questions or explain why questions cannot be answered.
Key Coverage Criteria
- Non‑invasive abdominal/visceral vascular studies are covered when the test results will be used to directly inform or change the patient's clinical management.
- A preoperative non‑invasive abdominal/visceral vascular study is covered as reasonable and necessary for patients undergoing bypass surgery (one preoperative scan considered reasonable).
- Medically necessary follow‑up non‑invasive abdominal/visceral vascular studies after angioplasty are covered as indicated by the vascular distribution treated.
- Non‑invasive abdominal/visceral vascular studies performed in the inpatient hospital (place of service 21) or emergency room (place of service 23) are permitted and are not subject to the routine once‑per‑year outpatient limitation.
- Studies are indicated for suspected stenosis of a visceral vein (renal, hepatic, mesenteric, portal, or splenic).
- Non-invasive abdominal/visceral vascular studies are medically necessary when signs or symptoms of ischemia or altered blood flow are present.
3 Active Policies
A57591 — Billing and Coding: Non-Invasive Abdominal / Visceral Vascular Studies
J05
L35755 — Non-Invasive Abdominal / Visceral Vascular Studies
J05
CIGNA-0548 — Scrotal Ultrasound - (0548)
Related Codes
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