S02.11ED — Type III occipital condyle fracture, right side, subsequent encounter for fracture with routine healing
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
Key Coverage Criteria
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- G71.21 | Nemaline myopathy
- G83.0 | Diplegia of upper limbs
- H44.19 | Other endophthalmitis
- H44.532 | Leucocoria, left eye
6 Active Policies
A57215 — Billing and Coding: MRI and CT Scans of the Head and Neck
A56612 — Billing and Coding: CT of the Head
A57204 — Billing and Coding: MRI and CT Scans of the Head and Neck
L34417 — CT of the Head
L35175 — MRI and CT Scans of the Head and Neck
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.