M12.452 — Intermittent hydrarthrosis, left hip
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation must describe pain and functional disability in context (e.g., interference with ADLs, pain with initiation or weight bearing).
- The medical record must include a history and physical, discharge summary, physician progress notes, and an operative report for the THA episode of care and must be made available to Noridian upon request.
- Imaging (X-ray, MRI, or CT) results must be in the record and should demonstrate the specific arthritic findings listed (e.g., subchondral cysts, sclerosis, osteophytes, subluxation, joint-space narrowing, avascular necrosis, bone-on-bone).
- Records must document conservative therapy attempts when appropriate (e.g., trial of NSAIDs, supervised physical therapy) or document contraindications to such therapy and show continued ADL impairment despite non-surgical management.
Key Coverage Criteria
- 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).
- THA is covered for joint malignancy when supporting evidence is in the record (e.g., pathology report and oncologist referral) demonstrating malignancy of the joint.
- THA or revision/replacement is covered for acute or chronic fracture when imaging (e.g., X-ray) documents the fracture and justifies the procedure.
- Revision or replacement THA is covered when pain at the hip is documented as a reason for the procedure (e.g., pain interfering with ADLs, pain increased with initiation of activity or weight bearing).
20 Active Policies
L39911 — Total Joint Arthroplasty
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
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