Does R94.31 require prior authorization?

No, R94.31 does not require prior authorization (high confidence). Code is covered without prior authorization.

`R94.31` — Abnormal electrocardiogram [ECG] [EKG]

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

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.
For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
If a service is likely to be non-covered, an Advance Beneficiary Notice (ABN) may be used and the appropriate modifier (GA, GX, GY, or GZ) should be appended to the claim as applicable.
Follow-up or limited transthoracic echocardiography performed to evaluate a single specified cardiac problem or region must be billed with CPT 93308.

L33560 — Cardiovascular Nuclear Medicine

J06

L33577 — Transthoracic Echocardiography (TTE)

J06

A56743 — Billing and Coding: Cardiovascular Nuclear Medicine

J06

A56781 — Billing and Coding: Transthoracic Echocardiography (TTE)

J06

A56952 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing

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