20985
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.44
Facility
$123.92
Non-Facility
$123.92
Documentation Required
- All documentation must be maintained in the patient's medical record, legible, include patient identification and dates of service, and be made available to the contractor upon request.
- Medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.
- Submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- For advanced joint disease document X-ray or MRI findings that demonstrate the specified imaging features (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis).
Key Coverage Criteria
- Total knee or hip arthroplasty is indicated for advanced joint disease (knee or hip arthritis) supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.
- Procedure is indicated when pain or functional disability interferes with activities of daily living (ADLs), increases with activity, or increases with weight bearing.
- Coverage requires unsuccessful conservative therapy, usually a reasonable attempt of 3 months or more, unless inappropriate for the patient; typical conservative measures include anti-inflammatory medications/analgesics, flexibility and strengthening exercises, supervised physical therapy, assistive devices, activity restrictions, weight reduction, and/or therapeutic intra-articular injections.
- Conservative management may be inappropriate (and therefore not required) when bone-on-bone articulation, severe deformity, or severe pain—particularly at rest—with significant ADL interference is present.
- Revision TKA or THA for infection is indicated when laboratory and/or pathology reports and documentation of infection treatment are present, along with a physician note that surgery is appropriate.
- When malignancy of the joint or fracture is the indication for TKA/THA, include supporting evidence such as pathology reports, oncologist referral, or fracture X-ray to support the procedure.
7 Active Policies
L40232 — Total Joint Arthroplasty
J18 MAC Part B
CGS-L40232 — Total Joint Arthroplasty
J18 MAC Part B
UMR-POL-UMR-computer-assisted-surg-nav-musculoskeletal-procs — Computer-Assisted Surgical Navigation for Musculoskeletal Procedures
UHC-POL-computer-assisted-surg-nav-musculoskeletal-procs — Computer-Assisted Surgical Navigation for Musculoskeletal Procedures
Related Codes
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