N73.5 — Female pelvic peritonitis, unspecified
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.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- Clinical notes supporting that the patient is certain about desire for permanent sterilization (i.e., not uncertain about ending fertility) and has not had prior tubal ligation if hysteroscopic approach is being considered.
- Hysterosalpingogram is necessary three months after surgery to verify micro-insert placement and tubal occlusion (manufacturer labeling / prescribing information) — i.e., modified HSG confirmation testing at three months
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
3 Active Policies
AETNA-CPB-0657 — Tubal Sterilization
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
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