R52 — Pain, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims and documentation requirements for CPNB are governed by and must follow the Local Coverage Determination L37641 referenced by this guideline.
- Medical record must include the ordering provider's assessment related to the patient's complaint, relevant medical history, and results of pertinent tests/procedures.
- The office visit record or operative report must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
- Claims must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and the reason(s) for the service.
Key Coverage Criteria
- No specific coverage indications are stated in this billing/coding guideline; refer to Local Coverage Determination L37641 for covered indications for continuous peripheral nerve blocks (CPNB).
- Excision of a benign skin lesion is covered when there is clinical suspicion of malignancy (e.g., ICD-10-CM D48.5) documented in the medical record.
- Removal is covered to address disturbance of skin sensation when documented (ICD-10-CM R20.0-R20.3, R20.8).
- Removal is covered when documented objective changes (e.g., increase in size) support a diagnosis warranting excision.
- Removal of a benign lesion is covered when the treating physician documents medical necessity for removal (physician judgment that lesion merits removal).
- Report histopathologic examination separately when performed using CPT codes 88304-88305.
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