R16.0 — Hepatomegaly, not elsewhere classified
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.
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- The ordering/referring practitioner's assessment related to the patient's complaint and the specific reason for the test must be documented in the medical record.
- The medical record must contain a referral/order on file for each non‑invasive vascular study performed.
Key Coverage Criteria
- Non-invasive vascular diagnostic tests are covered when ordered by the treating practitioner or a consulting physician who will use the results to manage the beneficiary's specific medical problem.
- A documented referral/order must be on record for each individual non-invasive vascular study performed for coverage to apply.
- Cerebrovascular arterial duplex follow-up is covered annually for stenosis 20–49% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 50–79% (diameter reduction).
- Cerebrovascular arterial duplex follow-up is covered every six months for stenosis 80–99% if surgical correction has not been performed.
- After carotid endarterectomy, repeat ipsilateral (unilateral) duplex examinations are allowable at approximately six weeks, six months, and one year post‑procedure during the first year.
16 Active Policies
L33627 — Non-Invasive Vascular Studies
J06
A56758 — Billing and Coding: Non-Invasive Vascular Studies
J06
A57636 — Billing and Coding: Duplex Scanning
J09
L33674 — Duplex Scanning
J09
ANTHEM-CG-SURG-106 — CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.