R10.A3 — Flank pain, bilateral
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must include the appropriate CPT code (88120 or 88121), 1 unit of service, and an appropriate ICD-10 diagnosis code for the clinical indication.
- Laboratories reporting only the technical component should append the TC modifier to CPT 88120 or 88121.
- Billing entities must be CLIA certified to submit UroVysion claims and should maintain CLIA certification documentation in the medical record/claims file.
- To bill a professional component, the physician must personally read, quantitate, and interpret the probe-stained cells/tissues and document that interpretive work in the medical record.
Key Coverage Criteria
- FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered when performed on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
- FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder cancer using urine specimens.
- Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
- A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
12 Active Policies
A55029 — Billing and Coding: Lab: Bladder/Urothelial Tumor Markers
ANTHEM-CG-LAB-24 — CG-LAB-24 Outpatient Urine Culture
ANTHEM-CG-LAB-35 — CG-LAB-35 Cancer Antigen 19-9 Testing
ANTHEM-CG-LAB-33 — CG-LAB-33 Carcinoembryonic Antigen Testing
ANTHEM-CG-LAB-32 — CG-LAB-32 Cancer Antigen 125 Testing
Related Codes
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