Z79.85 — Long-term (current) use of injectable non-insulin antidiabetic drugs
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims for stress tests performed as preoperative evaluation of asymptomatic, moderate-risk patients must include medical record documentation of at least one of: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.
- This article provides billing, coding and guideline information that complements Local Coverage Determination (LCD) L33431 for HbA1c; refer to LCD L33431 for clinical coverage criteria and specific documentation requirements.
- Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
- Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Key Coverage Criteria
- Preoperative cardiac stress testing with radionuclide imaging for asymptomatic patients deemed at moderate risk is covered only if the medical record documents at least one of the following: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.
- ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
- ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
- ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
- Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
- For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
20 Active Policies
A57484 — Billing and Coding: Vitamin D Assay Testing
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A56795 — Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)
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L40271 — MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
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A60305 — Billing and Coding: MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
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