22548
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
26.38
Facility
$1943.60
Non-Facility
$1943.60
Documentation Required
- All documentation must be maintained in the patient’s medical record, be legible, include patient identifiers and dates of service, and be made available to the contractor upon request.
- Operative note must document the procedure performed and any associated or additional procedures performed at the same time, and the CPT/HCPCS code submitted must describe the service performed.
- Medical record must include the performing provider’s assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and documentation to support the medical necessity of the procedure.
- All services ordered or rendered must be signed and dated; the record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
Key Coverage Criteria
- Cervical fusion and related cervical spine fusion procedures are the only procedures covered under this policy; other joint or non-cervical spinal procedures (e.g., facet, sacroiliitis, epidural) are not covered by this policy.
- Coverage for a cervical fusion procedure is allowed only when the service meets the reasonable and necessary clinical criteria and frequency limitations specified in the applicable draft Local Coverage Determination (LCD) Cervical Fusion.
- Cervical fusion procedures are covered when they meet the reasonable and necessary clinical criteria and frequency limits specified in Local Coverage Determination (LCD) L39788.
- Cervical fusion and related cervical-spine fusion procedures are within the scope of this billing/coding guidance and are covered when they meet the reasonable and necessary requirements in LCD L39793.
- This billing and coding guidance applies to cervical fusion and related cervical-spine procedures; follow LCD L39799 for reasonable and necessary coverage criteria.
- Cervical fusion for decompression of symptomatic cervical nerve root impingement when persistent or recurrent moderate or severe arm pain (VAS ≥4 or equivalent) has been present for ≥12 weeks within the current episode with documented failure of multimodal conservative management, nerve compression negatively impacts activities of daily living, other sources excluded, and MRI or CT shows central, lateral recess, or foraminal stenosis at the correlating level with at least one of: degenerative di [...]
20 Active Policies
L39788 — Cervical Fusion
J05
A59664 — Billing and Coding: Cervical Fusion
J05
A59632 — Billing and Coding: Cervical Fusion
J06
L39770 — Cervical Fusion
J06
A59674 — Billing and Coding: Cervical Fusion
Related Codes
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