S36.430S — Laceration of duodenum, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- For decisions about preoperative biliary drainage: documentation of rationale for PBD if performed given evidence that routine PBD may increase infectious complications
- Operative and peri-operative records documenting reconstruction technique (antecolic vs retrocolic), use of Braun anastomosis, omental/falciform wraps, stent placement, fibrin patch application, and rationale for such adjuncts (since evidence varies and practices may be individualized)
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
3 Active Policies
AETNA-CPB-0365 — Pancreaticoduodenectomy (Whipple Resection)
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
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