S12.040D — Displaced lateral mass fracture of first cervical vertebra, 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
- Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
- When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
- Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.
- Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.
Key Coverage Criteria
- CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
- CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
- G71.21 | Nemaline myopathy
- G83.0 | Diplegia of upper limbs
- H44.19 | Other endophthalmitis
20 Active Policies
A59664 — Billing and Coding: Cervical Fusion
J05
L39788 — Cervical Fusion
J05
A59632 — Billing and Coding: Cervical Fusion
J06
L39770 — Cervical Fusion
J06
L39799 — Cervical Fusion
J09
Related Codes
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