Does M48.56XA require prior authorization?

No, M48.56XA does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M48.56XA` — Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Documentation Required

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Title XVIII of the Social Security Act, §1842(p)(1) states that each claim submitted by a physician or practitioner shall include the appropriate diagnosis code (or codes)... For services from physicians and (§1842(b)(18)(C)) practitioner submitted with an ICD-10 code that is missing, invalid, or truncated, contractors must return the billed service to the provider as unprocessable in accordance with CR 1910, Transmittal 1728, dated November 1, 2001 (MCM Part 3, Claim Process §3005.4(p)).
42 CFR 410.32 and 410.33 indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.

Key Coverage Criteria

T82.535S | Leakage of umbrella device, sequela
M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
M84.38XS | Stress fracture, other site, sequela
M84.451A | Pathological fracture, right femur, initial encounter for fracture
S32.2XXD | Fracture of coccyx, subsequent encounter for fracture with routine healing
S32.2XXK | Fracture of coccyx, subsequent encounter for fracture with nonunion

20 Active Policies

A57604 — Billing and Coding: Intraoperative Neurophysiological Testing

J05

L34623 — Intraoperative Neurophysiological Testing

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

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §§40, 40.1.4 Magnetic Resonance Imaging (MRI) Procedures and Payment Requirements. Effective January 1, 2017 separate payment for the contrast media and the need to use the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, §§5-5.7.2 indicates that non-physician owned facilities performing primarily diagnostic tests should be enrolled as IDTFs rather than billing under physician PINs. See also 42 CFR 410.33.

L39139 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J06

A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J06

A59763 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

L39877 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A59764 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A59766 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J12

L39879 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J12

L39268 — Bone Mass Measurement

L39116 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

L36460 — Bone Mass Measurement

L37281 — Lumbar MRI

L37848 — Lumbar Spinal Fusion

L39118 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57207 — Billing and Coding: Lumbar MRI

L33942 — Physical Therapy - Home Health

A58867 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

M48.56XA — Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture