M25.511 — Pain in right shoulder
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each claim must be submitted with ICD-10-CM codes that reflect the patient's condition and the reason for the service; claims without ICD-10-CM codes will be returned.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- A permanent record of the ultrasound and its interpretation must be kept in the patient's record, including images labeled with exam date, patient identification, and image orientation; documentation of variations from normal with measurements; and a formal interpretation.
Key Coverage Criteria
- Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
- Follow the related Local Coverage Determination (LCD) for clinical indications and medical necessity criteria for reduction mammaplasty.
- 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.
- Cosmetic and reconstructive surgical services described are covered only when they meet the reasonable and necessary requirements of LCD L38914.
20 Active Policies
A59553 — Billing and Coding: Trigger Point Injections
J05
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
L39713 — Trigger Point Injections
J05
L39051 — Cosmetic and Reconstructive Surgery
J05
Related Codes
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