R62.51 — Failure to thrive (child)
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must comply with ICD-10-CM Coding Guidelines and the Local Coverage Determination (LCD) for Hospice The Adult Failure To Thrive Syndrome (L34558) when selecting and reporting the principal hospice diagnosis.
- Physician certification documenting that the beneficiary is terminally ill with a life expectancy of ≤ 6 months is required for Medicare hospice benefit eligibility.
- Documentation of BMI and level of disability (Karnofsky or PPS) measured/observed within 180 days (6 months) of the most recent certification/recertification date is required.
- If enteral nutritional support was in place before hospice election and will be continued, document BMI and disability at the time of initial certification and at each subsequent recertification.
Key Coverage Criteria
- Use only ICD-10-CM diagnosis codes that are valid to report as a principal diagnosis under ICD-10-CM Coding Guidelines when submitting a hospice principal diagnosis.
- Adult failure to thrive (FTT) syndrome with both nutritional impairment and disability is an indication for hospice when reversible causes of severe nutritional impairment/disability have been excluded.
- Beneficiaries with BMI < 22 kg/m2 who are declining enteral/parenteral nutritional support or have not responded to enteral/parenteral nutritional support despite adequate caloric intake meet the nutritional criterion for hospice eligibility.
- Significant disability defined as Karnofsky score ≤ 40% or Palliative Performance Scale (PPS) value ≤ 40% meets the functional criterion for hospice eligibility.
- A medical prognosis of life expectancy ≤ 6 months if the terminal illness runs its normal course supports hospice eligibility for adult FTT.
- If enteral nutritional support was instituted prior to hospice election and will be continued, the beneficiary may still qualify provided BMI and disability are documented at initial certification and at each subsequent recertification.
4 Active Policies
AMBETTER-CG-Exome-Genome-Gntc-DO-2025.1 — Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders
ANTHEM-CG-LAB-19 — CG-LAB-19 Laboratory Evaluation of Vitamin B12
A56679 — Billing and Coding: Hospice The Adult Failure To Thrive Syndrome
L34558 — Hospice The Adult Failure To Thrive Syndrome
Related Codes
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