S22.000B — Wedge compression fracture of unspecified thoracic vertebra, initial encounter for open 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.
- Bone mass measurement services are covered when they meet the clinical indications and medical necessity criteria specified in the related Local Coverage Determination L39268.
- Oximetry is medically necessary for patients exhibiting acute respiratory dysfunction signs or symptoms (tachypnea, dyspnea, cyanosis, respiratory distress, confusion, or hypoxia).
7 Active Policies
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
AETNA-CPB-0653 — Diphtheria, Tetanus, and Pertussis Vaccines
L39268 — Bone Mass Measurement
L36460 — Bone Mass Measurement
Related Codes
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