S31.609A — Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
- An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
- The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
- The medical record must document relevant medical history and the results of pertinent tests or procedures.
Key Coverage Criteria
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
- Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.
- Colonoscopy is covered for investigation of a positive fecal occult blood test.
- Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.
- Surveillance colonoscopy is covered for patients with a history of colorectal cancer or adenomatous polyps being followed for neoplasia surveillance.
- Colonoscopy to evaluate the entire colon for synchronous cancer or polyps in a patient with a treatable cancer or polyp is covered.
4 Active Policies
A57205 — Billing and Coding: Oximetry Services
J12
L35434 — Oximetry Services
J12
A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34005 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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