R77.8 — Other specified abnormalities of plasma proteins
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include complete patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- Every submitted medical record page must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- If the service provider differs from the ordering/referring physician, the performing provider must maintain hard copy documentation of test results and interpretation plus copies of the ordering/referring physician’s order for the studies.
Key Coverage Criteria
- Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
- CPT 78434 (gated SPECT) may be reported only in conjunction with CPT 78431 or CPT 78492 when billed for SPECT myocardial perfusion imaging (MPI).
- SPECT MPI includes routine evaluation of left ventricular wall motion and left ventricular ejection fraction (LVEF) as part of the MP1 service definition.
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
- EGD is covered for upper abdominal distress accompanied by a short history of concerning signs or symptoms such as weight loss, anorexia, vomiting, or NSAID/other gastric irritant intake.
6 Active Policies
A56952 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
J09
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L38396 — Cardiology Non-emergent Outpatient Stress Testing
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
Related Codes
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