S03.00XS — Dislocation of jaw, unspecified side, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.
- The medical record must document the medical necessity for performing MRI of the brain in addition to MRI of the orbit, face, and/or neck when both procedures are done on the same day.
- Pre-imaging documentation should include screening for contraindications (presence/absence of implanted neurostimulators, cochlear implants, pacemakers per CMS guidance, retained metal fragments in the eye, magnetic ocular implants, and intracranial aneurysm clips).
- When contrast material is administered, documentation should support the clinical indication for contrast-enhanced MRI.
Key Coverage Criteria
- No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
- MRI of the orbit, face, and/or neck is medically reasonable and necessary to diagnose or characterize pathology of the eye, nasopharynx, oropharynx, and neck including tumors, infection, soft-tissue pathologies, and congenital abnormalities.
- MRI with intravenous gadolinium-based or other indicated contrast agents may be used when contrast enhancement is required to visualize a body system or structure.
- An MRI of the brain may be performed on the same day as MRI of the orbit, face, and/or neck when clinically necessary, provided the medical record documents the medical necessity for both procedures.
3 Active Policies
A59840 — Billing and Coding: Magnetic Resonance Imaging of the Head and Neck
A56729 — Billing and Coding: Magnetic Resonance Imaging of the Head and Neck
L34425 — Magnetic Resonance Imaging of the Head and Neck
Related Codes
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