G07, Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
Key Coverage Criteria
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- Cerebral computed tomography (CT) perfusion studies for the emergent evaluation of acute cerebral ischemia (acute stroke) when either of the following criteria is met: CT perfusion studies will be used as a supplement to non-contrast head CT; or Magnetic resonance imaging is unavailable or contraindicated;
4 Active Policies
AETNA-CPB-0663, Cerebral Perfusion Studies
A56396, Billing and Coding: Lumbar Spinal Fusion
A57204, Billing and Coding: MRI and CT Scans of the Head and Neck
A57206, Billing and Coding: Lumbar MRI
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.