R59.1 — Generalized enlarged lymph nodes
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
- Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
- The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each claim must be submitted with ICD-10-CM codes that reflect the patient's condition and the reason for the service; claims without ICD-10-CM codes will be returned.
Key Coverage Criteria
- Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
- Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
- Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
- Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
- Ultrasound of soft tissues of the head and neck is covered when it is reasonable and necessary as defined by Local Coverage Determination L34027.
20 Active Policies
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
L33619 — Nonvascular Extremity Ultrasound
J06
A60186 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
A56787 — Billing and Coding: Nonvascular Extremity Ultrasound
J06
L40180
Related Codes
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