S22.088A — Other fracture of T11-T12 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.
- 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.
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.
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
16 Active Policies
A57630 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A57604 — Billing and Coding: Intraoperative Neurophysiological Testing
J05
L34623 — Intraoperative Neurophysiological Testing
J05
L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.