D16.21 — Benign neoplasm of long bones of right lower limb
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
Key Coverage Criteria
- Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
- 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.
- Total hip arthroplasty (THA) is covered for advanced hip joint disease when hip arthritis is documented by X-ray, MRI, or CT demonstrating one or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- THA is covered when the patient has hip pain or functional disability documented in context (e.g., pain interfering with ADLs, pain increased with initiation of activity, or pain increased with weight bearing).
- THA is covered when documentation shows unsuccessful conservative (non-surgical) therapy as appropriate for the current episode (e.g., documented trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
20 Active Policies
L39911 — Total Joint Arthroplasty
J05
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L36850 — Peripheral Nerve Blocks
J06
L33618 — Major Joint Replacement (Hip and Knee)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.