M84.378S — Stress fracture, left toe(s), sequela
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.
- Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.
- ESR performed for rheumatoid arthritis patients to assess the need for medication adjustments should be billed with a diagnosis code that reflects the specific antirheumatic medication the patient is receiving.
- Use ICD-10 codes T39.4X5A–T39.4X5S for ESR billing when the patient with rheumatoid arthritis is receiving antirheumatics such as gold salts for medication evaluation.
- Use ICD-10 codes T45.1X5A–T45.1X5S for ESR billing when the patient with rheumatoid arthritis is receiving antineoplastic or immunosuppressive drugs such as methotrexate for medication evaluation.
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
A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
L33619 — Nonvascular Extremity Ultrasound
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.