Does R19.5 require prior authorization?

No, R19.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`R19.5` — Other fecal abnormalities

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The submitted CPT/HCPCS code must accurately describe the service performed.
All documentation must be maintained in the patient 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.

Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Wireless capsule endoscopy is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L35089.

A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

L38837 — Colon Capsule Endoscopy (CCE)

J05

L35490 — Category III Codes

J05

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

A58471

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