M97.01XA — Periprosthetic fracture around internal prosthetic right hip joint, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims and coding must follow and reference the Local Coverage Determination L33456; consult L33456 for specific clinical coverage criteria and required documentation.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
Key Coverage Criteria
- Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
- Total hip arthroplasty (THA) is covered for advanced hip joint disease when hip arthritis is documented by X-ray, MRI, or CT demonstrating one or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- THA is covered when the patient has hip pain or functional disability documented in context (e.g., pain interfering with ADLs, pain increased with initiation of activity, or pain increased with weight bearing).
- THA is covered when documentation shows unsuccessful conservative (non-surgical) therapy as appropriate for the current episode (e.g., documented trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
- THA is covered for joint malignancy when supporting evidence is in the record (e.g., pathology report and oncologist referral) demonstrating malignancy of the joint.
- THA or revision/replacement is covered for acute or chronic fracture when imaging (e.g., X-ray) documents the fracture and justifies the procedure.
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
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
L39911 — Total Joint Arthroplasty
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.