C41.2 — Malignant neoplasm of vertebral column
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Use CPT code 81540 on the claim when billing for Cancer TYPE ID.
- Enter '1' in the Days/Unit field on the claim for this test.
- Submit the required test identifier information using SV101-7 or SV202-7 (SV202-7 preferred) or via the NTE field if needed.
- Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part B claims (Loop 2400 or SV101-7 for 5010A1 837P; Box 19 for paper claims).
Key Coverage Criteria
- Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
- CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
- Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
- Somatosensory testing is covered when medically reasonable and necessary and documented in the patient's medical record (relevant history, physical exam, and pertinent diagnostic test results).
- Testing and interpretation are covered when ordered and/or furnished by qualified personnel who have documented training and experience in evoked potentials and electrodiagnostics per CMS guidance (accredited residency/fellowship, national certification, or accredited post-graduate training/AMA-AOA Category 1 CME).
- The technical component may be furnished by a physical therapist with ABPTS certification without physician supervision, or by a certified technician under supervision consistent with the MPFSDB supervision level assigned to the CPT code (e.g., Level 21 for CPT 95925, 92526, 95927, 95938).
20 Active Policies
L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A57597 — Billing and Coding: Somatosensory Testing
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
L40277 — MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J05
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