S27.813A — Laceration of esophagus (thoracic part), initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
- All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Key Coverage Criteria
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- Therapeutic respiratory procedures (HCPCS G0237, G0238, G0239) using an individualized physical conditioning and exercise program with breathing techniques are covered for patients with documented activity limitations.
- Pulmonary function tests (PFTs) represented by CPT codes 94070, 94200, 94640, 94726, 94727, and 94729 are covered when reasonable and medically necessary with supporting clinical documentation and a written order by a physician or appropriate NPP.
- Spirometry (CPT 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726, 94727) is covered when clinically indicated and documented in the medical record.
- Lung volume determination (CPT 94013, 94726, 94727, 94728) and diffusion capacity testing (CPT 94729) are covered when medically necessary and documented.
- Pulmonary stress testing (CPT 94617, 94618, 94619, 94621) is covered when clinically indicated and supported by the medical record.
14 Active Policies
A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy
J09
L35434 — Oximetry Services
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A57414
Related Codes
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