22812
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
33.39
Facility
$1970.99
Non-Facility
$1970.99
Documentation Required
- All documentation must be maintained in the patient’s medical record, be legible, include appropriate patient identification (e.g., complete name, dates of service), and be available to the contractor upon request.
- Every page of the record must include appropriate patient identification information such as complete name and dates of service.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the selected ICD-10-CM diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- 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 is reasonable and necessary for decompression of symptomatic cervical nerve root impingement when persistent or recurrent moderate or severe arm pain (VAS ≥4) is present for ≥12 weeks in the current episode with documented failure of multimodal conservative management, nerve compression negatively impacts ADLs, other sources are excluded, and MRI/CT shows central, lateral recess, or foraminal stenosis at the level corresponding to clinical myotome signs with at least one structur [...]
- Exception to the conservative therapy requirement: presence of concomitant myelopathy or myeloradiculopathy (e.g., cervical myelopathy class III or higher) or progression of neurological deficits during a trial of conservative treatment qualifies for cervical fusion for decompression/stabilization.
- Exception to the conservative therapy requirement: isolated radiculopathy with progressive motor weakness, significant motor weakness interfering with ADLs, severe radicular pain (VAS ≥7) with confirmatory CT/MRI and clinical-radiological correlation, or loss of bowel or bladder control qualifies for surgery.
- Cervical fusion is reasonable and necessary for decompression of symptomatic cervical central (canal) stenosis when persistent or recurrent moderate or severe arm pain (VAS ≥4) for ≥12 weeks with failed conservative management, or when nerve compression negatively impacts ADLs or causes spastic gait, loss of manual dexterity, or sphincter problems, and MRI/CT demonstrates central stenosis at the corresponding level with at least one structural cause (degenerative disease, congenital short pedicl [...]
7 Active Policies
L39799 — Cervical Fusion
J09
A59674 — Billing and Coding: Cervical Fusion
J09
L39793 — Cervical Fusion
J12
A59668 — Billing and Coding: Cervical Fusion
J12
CARELON-spine-surgery-2024-01-01 — Spine Surgery
Related Codes
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