R56.9 — Unspecified convulsions
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient medical record, be legible, include patient identification and the identity of the physician or non-physician practitioner responsible for care, and be available to the contractor upon request.
- Medical record documentation maintained by the ordering/treating physician must indicate the medical necessity and clinical indication(s) that led to ordering the drug test and support the selected diagnosis and CPT/HCPCS code(s).
- All tests must be ordered in writing by the treating provider and the order must specify all drugs/drug classes to be tested; the physician’s order must include the clinical indication/medical necessity.
- If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy documentation of lab results and copies of the ordering physician’s order for the drug test.
Key Coverage Criteria
- Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
- Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
- Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
- Ambulatory EEG is covered for diagnostic evaluation when seeking to detect clinical seizures or interictal epileptiform activity.
- Ambulatory EEG is covered for pre-surgical evaluation to localize seizure onset when capture of multiple seizures is needed for surgical planning.
- Ambulatory EEG is covered for routine follow-up monitoring of known seizure disorder or previously identified epileptiform activity.
20 Active Policies
A56915 — Billing and Coding: Urine Drug Testing
J05
L34645 — Urine Drug Testing
J05
A57030 — Billing and Coding: EEG Ambulatory Monitoring
J06
L33399 — EEG Ambulatory Monitoring
J06
A59416 — Billing and Coding: Urine Drug Testing
Related Codes
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