M25.862 — Other specified joint disorders, left knee
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims must be supported by documentation required by LCD L34576 (medical records demonstrating eligibility, medical necessity, and any prior authorization if applicable).
- Follow payer-specific coding, modifiers, and claim form requirements for laparoscopic sleeve gastrectomy as outlined in this billing/coding guidance and the LCD.
- All documentation must be maintained in the patient's medical record, be legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Billing and coding guidance applies to laparoscopic sleeve gastrectomy (sleeve gastrectomy) performed for severe obesity and is intended to complement LCD L34576.
- Use this policy's billing/coding rules when submitting claims for laparoscopic sleeve gastrectomy; follow the clinical indication criteria in LCD L34576 for medical necessity determinations.
- Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
- Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.
- THA or TKA is covered when the patient has pain or functional disability at the hip or knee, e.g., pain interfering with activities of daily living (ADLs), pain increased with initiation of activity, or pain increased with weight bearing.
- THA or TKA is covered when there is documentation of unsuccessful conservative therapy appropriate to the episode of care, generally a reasonable attempt of usually 3 months or more (e.g., trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
20 Active Policies
L39911 — Total Joint Arthroplasty
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L39624 — 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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