Does R63.5 require prior authorization?

No, R63.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`R63.5` — Abnormal weight gain

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

All supporting medical documentation (including the Plan of Care) must be maintained in the patient's medical record, be legible, include patient identifiers and dates of service, and be made 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 the patient's care.
The submitted medical record must support the selected ICD-10-CM diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed; the record must support medical necessity of billed services.
Monthly claims using Bill Type 72X with Revenue Codes 0821 and 0881 must follow the three available per-line billing approaches based on the patient's Plan of Care and other medical documents.

For ESRD patients, routine in-facility or home hemodialysis furnished 3 times per week should be billed as CPT/HCPCS code 90999 with no modifier and will be paid as routine conventional dialysis (up to 13/14 sessions per month).
Dialysis sessions furnished in addition to 3 sessions per week may be considered for additional payment when supported by medical documentation demonstrating the extra sessions are reasonable and necessary; such sessions should be billed as 90999 KX.
For clinical conditions (including acute and some chronic conditions) with supporting documentation from recent hospital care, office visits, dialysis progress notes, or MCP visits, extra sessions may be justified and billed with modifier KX for consideration of additional payment.
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.

A55703 — Billing and Coding: Frequency of Hemodialysis

J05

L37537 — Frequency of Hemodialysis

J05

L37475 — Frequency of Hemodialysis

J06

A55672 — Billing and Coding: Frequency of Hemodialysis

J06

L37564 — Frequency of Hemodialysis

Ask Verity about documentation requirements, denial risks, or coverage in your state.