R65.11 — Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- An interpretation and report must be a complete, separately identifiable written report addressing findings, relevant clinical issues, comparative data (when available), and must be included in the medical record.
- The patient's medical record must be legible and clearly document the reasonableness and necessity of the ECG and show that the service was necessary for at least one covered condition in the policy.
- A laboratory or portable X‑ray supplier that furnishes an ECG must retain the referring physician’s written order and the identity of the employee who took the tracing.
- An ECG furnished on an emergency basis by a laboratory or portable X‑ray supplier requires a physician to be in attendance at the time the service was performed or immediately thereafter to support payment.
Key Coverage Criteria
- An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
- A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
- Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
- Home-based ECG services (including additional payment above the base ECG amount for transportation) are covered when there is a documented medical need to perform the ECG in the patient's home, typically for homebound or bed-confined patients.
- A second professional component (PC) interpretation may be paid when a second physician’s substantially greater expertise is necessary and reasonable to clarify a questionable or confusing ECG finding and contributes substantially to diagnosis or treatment.
- S22.21XS | Fracture of manubrium, sequela
3 Active Policies
A57327 — Billing and Coding: Electrocardiograms
A57326 — Billing and Coding: Electrocardiograms
L34315 — Electrocardiograms
Related Codes
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