Does Q35.5 require prior authorization?

No, Q35.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Q35.5` — Cleft hard palate with cleft soft palate

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

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.
Services that meet the Medicare reasonable and necessary requirements per Local Coverage Determination (LCD) L35090 are covered when billed as reconstructive or medically necessary procedures.

A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery

J05

L39051 — Cosmetic and Reconstructive Surgery

J05

L38914 — Cosmetic and Reconstructive Surgery

J09

A58573 — Billing and Coding: Cosmetic and Reconstructive Surgery

J09

L35090

Ask Verity about documentation requirements, denial risks, or coverage in your state.