Z43.6 — Encounter for attention to other artificial openings of urinary tract
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes per Final Rule 1713 and the LCD-related Standard Documentation Requirements Article (A55426); claims missing these will be denied.
- For quantities of supplies that exceed the usual maximum amount, the medical record must explain the need for the increased amount and be available upon request.
- Initial justification for medical need must be established at the time the ostomy item is first ordered; once initial need is established, ongoing need is assumed and no further documentation is required as long as the beneficiary continues to meet the Prosthetic Devices benefit.
- Claims for tape and adhesive (A4450, A4452, A5120) must include an AU modifier or another appropriate modifier indicating alternate coverage; absence of such modifier will cause rejection for missing information.
Key Coverage Criteria
- Ostomy supplies are covered under the Prosthetic Device benefit for beneficiaries with a permanent impairment requiring an ostomy; permanence means a condition of long and indefinite duration as documented by the treating practitioner.
- Ostomy supplies are covered for use on beneficiaries with a surgically created opening (stoma) to divert urine or fecal contents, including colostomy, ileostomy, and urinary ostomy.
- Outpatient urine culture testing for bacteria is consideredmedically necessaryto evaluate any of the following situations:
- Clinical signs or symptoms suggesting urinary tract infection (UTI);or
- Abnormal urinalysis suggesting UTI;or
- Asymptomatic bacteriuria in pregnant persons;or
2 Active Policies
A52487 — Ostomy Supplies - Policy Article
J19
ANTHEM-CG-LAB-24 — CG-LAB-24 Outpatient Urine Culture
Related Codes
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