S12.01XA — Stable burst fracture of first cervical vertebra, initial encounter for closed fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All services ordered or rendered to Medicare beneficiaries must be signed; providers/suppliers must notify beneficiaries in writing prior to rendering the service if aware the test/item/procedure may not be covered.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition must be reported on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
Key Coverage Criteria
- Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
- An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
- A DXA confirmatory test may be performed and covered as a baseline for future monitoring (exception to the 'one type only' rule).
- CPT code 77082 (vertebral fracture assessment) is covered when medically necessary, with symptoms documented and when results are anticipated to be used in patient management.
- 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.
18 Active Policies
A57604 — Billing and Coding: Intraoperative Neurophysiological Testing
J05
L34623 — Intraoperative Neurophysiological Testing
J05
L39799 — Cervical Fusion
J09
A59674 — Billing and Coding: Cervical Fusion
J09
A57205 — Billing and Coding: Oximetry Services
Related Codes
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