Q18.4 — Macrostomia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Maintain all documentation in the patient’s medical record; every page must be legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
- The submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Speech-language pathology (SLP) services for treatment or evaluation of communication disorders when determined reasonable and necessary per LCD L35070.
- Selection and prescription of speech-generating devices should be billed with CPT code 92607.
- Adaptation and training for speech-generating devices should be billed with CPT code 92609.
- Report group therapy with CPT code 92508 when patients are not receiving direct one-on-one contact and are supervised by the therapist.
- Use the appropriate CPT evaluation code for re-evaluations in SLP because CPT does not define a distinct re-evaluation code.
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
7 Active Policies
A54111 — Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders
J12
L35070 — Speech - Language Pathology (SLP) Services: Communication Disorders
J12
A57215 — Billing and Coding: MRI and CT Scans of the Head and Neck
L35175 — MRI and CT Scans of the Head and Neck
L37373 — MRI and CT Scans of the Head and Neck
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.