ICD-10 N20.1 is officially defined as "Calculus of ureter." code N20.1 is referenced in 3 tracked payer policy changes from Blue Cross Blue Shield of North Dakota, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code N20.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Blue Cross Blue Shield of North Dakota is expanding coverage for Vitamin D Testing by adding 12 new diagnosis codes, including Crohn's disease and kidney stone conditions. This allows billing for Vitamin D tests when patients have these newly covered diagnoses.
Aetna covers urinary catheters and external urinary collection devices as medically necessary prosthetics for members with permanent urinary incontinence or permanent urinary retention, where retention is not expected to be medically or surgically corrected within 3 months. Aetna considers one indwelling catheter per month medically necessary for routine catheter maintenance, and the policy lists usual maximum quantities for insertion trays, drainage bags, intermittent catheters, lubricant and external collection devices. The inFlow device is considered medically necessary as an alternative to intermittent catheterization for permanent urinary retention due to impaired detrusor contractility, with one device no more than once every 29 days, and the PureWick urine collection system is considered unproven and not medically necessary for the management of urinary incontinence.
Extracorporeal shock wave therapy, whether high-dose, low-dose or radial, is considered investigational for musculoskeletal conditions including plantar fasciitis, tendinitis of the shoulder, elbow, Achilles and patellar tendons, spasticity, stress fractures, delayed union and nonunion of fractures, and avascular necrosis of the femoral head. Shock wave therapy for salivary stones is investigational, while shock wave therapy for kidney stones is considered eligible for coverage. The Federal Employee Program may dictate that FDA-approved devices are not considered investigational and may be assessed only on the basis of medical necessity.
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