R60.1 — Generalized edema
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The final report must include an impression or summary statement, a specific or differential diagnosis if appropriate, and recommendations for follow-up when clinically applicable.
- All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.
- 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
- Doppler ultrasound (peripheral venous ultrasound) is the standard preoperative test to evaluate venous reflux in patients with chronic venous insufficiency.
- CPT 93971 should be used to report either a limited bilateral duplex scan or a complete unilateral duplex scan for peripheral venous reflux evaluation.
- Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
- Each dialysis session performed for an ESRD patient must be reported on a separate line for dates of service on or after 2007-04-01.
- When the hemodialysis prescription is three times per week and each session is furnished, bill each session as CPT 90999 with no modifier; these sessions will be paid as routine conventional dialysis.
- Dialysis sessions furnished in addition to three per week that have medical documentation supporting reasonable and necessary need should be billed as CPT 90999 with the KX modifier for consideration of additional payment.
20 Active Policies
L37537 — Frequency of Hemodialysis
J05
A55703 — Billing and Coding: Frequency of Hemodialysis
J05
A56758 — Billing and Coding: Non-Invasive Vascular Studies
J06
L33577 — Transthoracic Echocardiography (TTE)
J06
L33627 — Non-Invasive Vascular Studies
Related Codes
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