R10.816 — Epigastric abdominal tenderness
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.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- When billed outside the specified POS, the test is covered if ordered by a diagnosing/treating specialist in Infectious Diseases, Gastroenterology, Oncology, or Transplant, with specialist communication documented in the medical record.
- Multiplex GPP tests for diagnosis of acute gastroenteritis (AGE) are covered when billed in POS 20, 21, 22, 23, or 81.
- Multiplex GPP tests are covered when ordered as part of a pre-transplant evaluation for an immunocompromised beneficiary and billed in POS 81 (Independent Laboratory).
- An access-based exception may permit coverage for tests ordered by non-specialists outside the specified POS when the beneficiary cannot reasonably reach a specialist (e.g., rural or island locations) and the ordering provider is closer to the beneficiary; this must be documented.
- EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
6 Active Policies
A58963 — Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)
J06
L39226 — Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)
J06
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
Related Codes
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