R12 — Heartburn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
- All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
- 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).
Key Coverage Criteria
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
- A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
- Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
- Home-based ECG services (including additional payment above the base ECG amount for transportation) are covered when there is a documented medical need to perform the ECG in the patient's home, typically for homebound or bed-confined patients.
- A second professional component (PC) interpretation may be paid when a second physician’s substantially greater expertise is necessary and reasonable to clarify a questionable or confusing ECG finding and contributes substantially to diagnosis or treatment.
12 Active Policies
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
Related Codes
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