O12.25 — Gestational edema with proteinuria, complicating the puerperium
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record must reflect how the cystatin C test result was used in the patient's plan of care.
- Medical records must be maintained and legible, include complete patient identification and dates of service, and include the legible signature of the responsible physician or non-physician practitioner.
- The submitted medical record must support the selected ICD-10-CM code(s) and show medical necessity for the cystatin C test.
- The laboratory or billing provider must retain a physician requisition that states the diagnosis/ICD-10-CM code that warrants the test.
Key Coverage Criteria
- Cystatin C measurement is covered when medical record documents an adult patient (>=18 years) with a creatinine-based eGFR of 45–59 ml/min/1.73 m2 and no markers of kidney damage.
- Cystatin C measurement is covered when the ordering documentation demonstrates that creatinine-based GFR estimates are believed to be inaccurate and more accurate GFR knowledge will affect clinical decision-making or the patient's plan of care.
- Cystatin C testing is medically reasonable and necessary when all of the following are met: adult with serum creatinine–based eGFR 45–59 ml/min/1.73 m2 (CKD stage 3A) without markers of kidney damage; serum creatinine–based GFR is suspected to be inaccurate; and confirmation of GFR will affect clinical decisions (e.g., confirming CKD diagnosis, determining kidney donation eligibility, or adjusting dosage of renally excreted toxic drugs).
2 Active Policies
A57643 — Billing and Coding: Lab: Cystatin C Measurement
L37616 — Lab: Cystatin C Measurement
Related Codes
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