M17.11 — Unilateral primary osteoarthritis, right knee
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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.
- Intra-articular hyaluronan injections are covered for pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.
- Intra-articular hyaluronan injections may be used as a therapeutic option for osteoarthritis of the shoulder.
- Bariatric surgery for treatment of co-morbid conditions related to morbid obesity is payable when billed in accordance with CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1 Part 2 Section 100.1.
- Additional diagnoses listed in this local coverage article for Part A procedure codes and the article's listed CPT codes are covered for bariatric surgery to treat co-morbid conditions related to morbid obesity.
- Intraarticular hyaluronan is covered for treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond adequately for at least 3 months to simple analgesics and conservative nonpharmacologic therapy (exercise/physical therapy, weight loss if appropriate, use of assistive devices).
20 Active Policies
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
A54923 — Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
J05
L39529 — Intraarticular Knee Injections of Hyaluronan
J05
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