M19.011 — Primary osteoarthritis, right shoulder
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The medical record must document relevant medical history, physical examination, pertinent diagnostic test/procedure results, and history of pharmacologic therapy supporting medical necessity.
- Documentation for subsequent courses must clearly establish reduction in patient symptomatology and medication usage and must be available upon request.
- Append appropriate site modifier (RT or LT) to CPT 20610/20611 for unilateral services and modifier 50 to indicate bilateral services.
- Use the EJ modifier on drug codes to indicate subsequent injections of a series; do not use EJ for the first injection of each series.
Key Coverage Criteria
- 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.
- Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
- Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
- Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
- Total shoulder arthroplasty is covered when the medical necessity criteria of the Local Coverage Determination L39956 are met.
20 Active Policies
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
A52420 — Billing and Coding: Hyaluronans Intra-articular Injections of
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
Related Codes
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