M97.11XA — Periprosthetic fracture around internal prosthetic right knee 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 knee arthroplasty (TKA/TKR) is covered for advanced joint disease of the knee when imaging (X-ray, MRI, or CT) documents one or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- TKA/TKR is covered when the patient has knee pain and/or functional disability that interferes with activities of daily living (ADLs) or pain that increases with initiation of activity or with weight bearing.
- TKA/TKR is covered after unsuccessful conservative (non-surgical) therapy when documentation shows a reasonable trial such as NSAIDs (or documented contraindication) and/or supervised physical therapy, with persistent ADL impairment despite non-surgical care.
- Revision or replacement TKA/TKR is covered for appropriate indications (e.g., pain, infection, malignancy, fracture) when supporting evidence is documented such as pathology reports, oncologist referral for joint malignancy, imaging for fracture, or other relevant studies.
- When infection is the indication for revision TKA/TKR, coverage requires laboratory and/or pathology reports, documentation of infection treatment, and a physician note stating it is appropriate to proceed with surgery.
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
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