29877
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.09
Facility
$586.85
Non-Facility
$586.85
Documentation Required
- Medicare contractors may require operative notes, reports of standing x-rays, and/or arthroscopy results to define the patient’s knee condition when adjudicating coverage.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition must be submitted on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
- An Advance Beneficiary Notice of Noncoverage (ABN) may be used for outpatient services likely to be non-covered; follow CMS Claims Processing Manual Chapter 30 guidance when issuing ABNs.
Key Coverage Criteria
- Arthroscopic lavage or arthroscopic debridement for osteoarthritic knee in patients WITHOUT severe osteoarthritis who present with mechanical symptoms (eg, locking, snapping, popping), abnormal limb/knee alignment, or less severe/early degenerative arthritis may be considered for coverage at the discretion of the Medicare contractor.
- Surgery of the knee is proven and medically necessary in certain circumstances (see InterQual® CP: Procedures).
- Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee
- Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
- Refer to InterQual® CP: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee
- Refer to InterQual® CP: Arthrotomy, Knee
8 Active Policies
A52369 — Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Medical Policy Article
J06
CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery
CARELON-level-of-care-for-surgical-procedures-2025-11-15 — Level of Care for Surgical Procedures
UHC-POL-surgery-knee — Surgery of the Knee
Related Codes
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