M71.30 — Other bursal cyst, unspecified site
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For multiple injection sites, the record must document the reason for injecting each site and substantiate that all injections were reasonable and necessary.
- The medical record must document medical necessity including relevant history, physical exam, and results of pertinent diagnostic tests or procedures supporting the indication for the injection.
- The procedure note must be legible and include techniques used, site(s) of injection, drugs with doses/volumes/concentrations, and pre- and post-procedural pain assessments.
- When a referring/ordering physician is required, the referring/ordering physician's name and NPI must be reported on the claim; claims without a valid ICD-10-CM diagnosis code will be returned as incomplete.
Key Coverage Criteria
- Injection into tendon sheaths, ligaments, ganglion cysts, carpal tunnel, or tarsal tunnel is covered when medically necessary to diagnose or treat local pain and the medical record documents the clinical reason for the injection at each site.
- Diagnostic injections to identify a painful structure are covered when performed no sooner than one week (preferably two) apart and limited to no more than two injections in the diagnostic phase.
- Therapeutic injections are covered when a patient had diagnostic injections demonstrating initial pain relief of ≥75–100% with return of function and maintains ≥50% pain relief and functional improvement for at least six weeks.
- Diagnostic or therapeutic injection into the paravertebral facet joint or the nerves innervating that joint for pain management is covered for cervical/thoracic and lumbar/sacral regions when consistent with the LCD.
- Thermal neurolytic destruction (radiofrequency ablation) of nerves innervating facet joints is covered in cervical/thoracic and lumbar/sacral regions per CPT codes 64633–64636 when documentation supports medical necessity.
- Unilateral or bilateral facet interventions are permitted during the same session and a bilateral intervention at the same vertebral level is considered a single level for counting/reporting purposes.
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
L40268 — Pain Management - Injection of tendon sheaths, ligaments, bursa, and ganglion cysts
J06
A52863 — Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels
J06
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