T85.611A — Breakdown (mechanical) of intraperitoneal dialysis catheter, 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
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- T82.535S | Leakage of umbrella device, sequela
- M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
- M84.38XS | Stress fracture, other site, sequela
6 Active Policies
A57207 — Billing and Coding: Lumbar MRI
A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A57206 — Billing and Coding: Lumbar MRI
L34220 — Lumbar MRI
L37281 — Lumbar MRI
Related Codes
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