22554
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
17.25
Facility
$1216.13
Non-Facility
$1216.13
Documentation Required
- For diagnostic tests, report the test result if known; otherwise report the symptoms that prompted the performance of the test.
- All documentation must be maintained in the patient's medical record, be legible, include appropriate patient identification and service dates, and include the legible signature of the physician or non-physician practitioner responsible for the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed; the operative note must document the procedure performed and any associated or additional procedures performed at the same time.
- The patient's medical record should include the performing provider's assessment related to the patient's complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
Key Coverage Criteria
- Cervical fusion and related procedures are covered when they meet the reasonable and necessary clinical criteria and frequency limits specified in Local Coverage Determination (LCD) L39738.
- Cervical fusion and related cervical spine fusion procedures are covered when they meet the reasonable and necessary clinical and frequency criteria specified in Local Coverage Determination (LCD) L39758.
- 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.
- This billing/coding guidance applies only to cervical fusion and related cervical spine procedures and does not apply to other joint or non-cervical spinal procedures (e.g., facet, sacroiliitis, epidural, other spinal procedures).
- Cervical fusion procedures are covered when they meet the reasonable and necessary clinical criteria and frequency limits specified in Local Coverage Determination (LCD) L39788.
15 Active Policies
L39788 — Cervical Fusion
J05
A59664 — Billing and Coding: Cervical Fusion
J05
A59632 — Billing and Coding: Cervical Fusion
J06
L39770 — Cervical Fusion
J06
L39799 — Cervical Fusion
J09
Related Codes
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