R40.2354 — Coma scale, best motor response, localizes pain, 24 hours or more after hospital admission
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
- Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
- Ambulatory continuous EEG is covered only if a prior routine “resting” EEG was performed before the ambulatory EEG.
- Routine EEGs covered under this policy are those described by CPT codes 95812, 95813, 95816, 95819, or 95822.
- A routine EEG is defined as a recording of less than a 24-hour continuous duration.
- Ambulatory EEG is indicated when a seizure diathesis is suspected but not defined by history, physical exam, or routine resting EEG.
4 Active Policies
A56645 — Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing
J12
L35006 — Controlled Substance Monitoring and Drugs of Abuse Testing
J12
A56771 — Billing and Coding: Special Electroencephalography
L33447 — Special Electroencephalography
Related Codes
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