S22.012A — Unstable burst fracture of first thoracic 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
- This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.
- Follow LCD L35434 for reasonable and necessary requirements and supporting medical documentation for oximetry services.
- Report overnight oximetry using CPT code 94762 on claims.
- A valid, written, physician-signed and dated plan of treatment must be established prior to provision of physical therapy and must outline type, amount, frequency, duration, functional diagnosis deficits, and anticipated short- and long-term goals.
Key Coverage Criteria
- Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
- Beneficiary is under the care of a physician.
- Beneficiary is receiving services under a plan of care that is established and periodically reviewed by a physician.
- Beneficiary needs skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology, or has a continued need for occupational therapy.
- Physical therapy services ordered by a physician and provided by a qualified physical therapist or under the general supervision of a qualified physical therapist are covered when reasonable and necessary to treat illness/injury or to restore or maintain function.
- Physical therapy services provided as a result of a valid written, physician-signed and dated plan of treatment established prior to provision that specifies type, amount, frequency, duration, functional diagnosis deficits, and short- and long-term goals are covered.
10 Active Policies
L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A57604 — Billing and Coding: Intraoperative Neurophysiological Testing
J05
A57630 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
L34623 — Intraoperative Neurophysiological Testing
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.